IJE Advance Access originally published online on August 30, 2006
International Journal of Epidemiology 2006 35(5):1136-1139; doi:10.1093/ije/dyl195
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Cochrane Column |
Cochrane Column
South African Cochrane Centre, Medical Research Council, PO Box 19070, Tygerberg 7505, South Africa. E-mail: taryn.young{at}mrc.ac.za
Road traffic injuries are a major cause of morbidity and mortality globally. This month we highlight a review by Ehiri et al. on the interventions for promoting booster seat use in 4–8 year olds travelling in motor vehicles.
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The aim of the Column is to highlight Cochrane systematic reviews of relevance to public health and to stimulate debate on relevance, feasibility, and acceptability. The Cochrane Collaboration (http://www.cochrane.org) is an international, non-profit organization that prepares and disseminates up-to-date systematic reviews on the effects of healthcare interventions in order to help people make well-informed decisions. Systematic reviews aim to answer focused healthcare questions by systematically identifying and evaluating all relevant research studies and synthesizing their results.
If you are interested in contributing to the Cochrane Column or The Cochrane Collaboration, contact me at the South African Cochrane Centre.
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A summary of Cochrane reviews (and protocols) of relevance to health promotion and public health can be viewed on the Cochrane Health Promotion and Public Health website: http://www.vichealth.vic.gov.au/cochrane/
Interventions to increase booster seat use among 4–8 year olds: A Cochrane review
* Corresponding author. Department of Maternal & Child Health, School of Public Health, University of Alabama at Birmingham, 1665 University Boulevard, Ryals Building, Birmingham, AL, USA. E-mail: jehiri{at}uab.edu
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Background |
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Motor vehicle injuries involving children are a significant public health problem.1 Globally, such injuries have been reported to affect many young people, resulting in a large number of years lost to premature death or a large number of years lived with disability.2 Children aged 4–8 years are especially important since they die more as occupants in motor vehicle crashes than from any other form of unintentional injury.3 As children of this age group outgrow safety seats designed for them, they travel mostly unrestrained in motor vehicles or are placed prematurely in adult seat belts instead of booster seats recommended by public health and transport safety agencies.4–7 This increases their risk for serious crash-related injuries, disabilities, psychological trauma, and mortality.8–11
To reduce the burden of traffic-related injuries and mortalities, public health and traffic safety agencies recommend that children aged 4–8 years use booster seats when travelling in motor vehicles until they are at least 58 inches tall, have a sitting height of 29 inches and weigh 
80 lbs. It is known that booster seats markedly reduce the odds of children sustaining clinically significant injuries in a crash in comparison with using adult seatbelts.12 Yet, evidence shows that very few children are restrained in age-appropriate booster seats when travelling in motor vehicles.13 This review assessed the effectiveness of interventions aimed at increasing acquisition and use of booster seats in motor vehicles among 4–8 year olds.
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Methodology |
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Search strategy
We searched the Cochrane Injuries Group Specialized Register (Issue 2, 2005), the Cochrane Central Register of Controlled Trials (Issue 2, 2005), EMBASE (1980–April 2005), LILACS (1982–April 2005), MEDLINE (1966–April 2005), TRANSPORT (1976–April 2005), ERIC (all years up to April 2005), CINAHL (1982–June 2005), The Campbell Collaboration's Social, Psychological, Educational, and Criminological Trials Register (SPECTR), the Australian Transport Index (formerly ARRB and ATRI) (1976–April 2005), and various transport research databases. We also contacted experts and examined reference lists of published studies. The search was not restricted by publication status or language.
Selection criteria
We included randomized controlled trials and controlled before-and-after studies that investigated the effects of interventions to increase use of booster seats. Intervention types were booster seat distribution and education programmes, incentive and education programmes, enforcement of booster seat laws, and education-only programmes. Two authors assessed study eligibility and methodological quality using pre-defined criteria. Five studies met inclusion criteria for this review. Data were extracted using a standard abstraction form and missing data were requested from authors.
Data analysis
Four intervention types were identified and examined: (i) education vs no intervention; (ii) distribution-and-education vs no intervention; (iii) incentives-and-education vs no intervention; and (iv) enforcement vs no intervention.
We calculated relative risks (RRs) with 95% confidence intervals (95% CIs) in the analysis of the effects of each intervention type, using the fixed effect model. To estimate the combined effect of all booster seat promotion interventions as compared with no intervention, we analysed data from all four intervention types as one large group vs no intervention, using the random effects model.
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Results |
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All five studies assessed observed or self-reported booster seat use. Studies included three peer-reviewed articles, an unpublished conference proceeding, and a thesis. Three were randomized controlled trials. Intervention types showed a beneficial effect on booster seat use. Distribution-and-education had the greatest effect compared with no intervention, followed by education and incentive-and-education. Enforcement vs education showed no effect (RR = 1.04; 95% CI 0.91–1.20). All intervention types combined showed a marked beneficial outcome for booster seat use (RR = 2.18; 95% CI 1.12–4.23).
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Conclusions |
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Interventions which combine education with either incentives or distribution of free booster seats have a beneficial effect on acquisition and use of booster seats. Results can have significant implications on the establishment of future interventions. Public–private partnerships might be one avenue for funding distribution-and-education programs.
The full text of the Cochrane Review is available in The Cochrane Library: Ehiri JE, Ejere HOD, Magnussen L, Emusu D, King W, Osberg JS. Interventions for promoting booster seat use in 4–8 year olds traveling in motor vehicles. The Cochrane Database of Systematic Reviews 2006, Issue 1. Art. No.: CD004334 [GenBank] .pub2. DOI: 10.1002/14651858.CD004334.pub2.
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References |
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1 United Nations Children's Fund. A league table of child deaths by injury in rich nations. Florence, Italy: Innocenti Research Center, UNICEF, February 2001. Available at: www.unicef-icdc.org/publications/pdf/repcard2e.pdf (Accessed: May 13, 2006).
2 Krug EG, Sharma GK, Lozano R. The global burden of injuries. Am J Public Health 2000;90:523–26.
3 Centers for Disease Control and Prevention. Ten leading causes of death, United States 2001. Atlanta GA: U.S. Department of Health and Human Services, 2004. Available at: http://webapp.cdc.gov/sasweb/ncipc/leadcaus.html (Accessed: May 13, 2006).
4 Australia Transport Safety Bureau. A simple guide to child restraints: how you can protect your child. Australia Transport Safety Bureau, Road Safety Division, 2005. Available at: http://www.atsb.gov.au/pdfs/child_restraints.pdf (Accessed May 13, 2006).
5 Department for Transport, UK. Press notice, April 14, 2004: Children up to 11 still need car seats says the DFT's THINK! Campaign. THINK! Road Safety Campaigns, London: Department for Transport, 2004. Available at: www.thinkroadsafety.gov.uk/campaigns/childcarseats/pn040414.htm (Accessed May 13, 2006).
6 National Highway Traffic Safety Administration. Booster seat study: improving the safety of child restraints. Report to Congress. Washington DC: U.S. Department of Transportation, National Highway Traffic Safety Administration, 2002. Available at: www-nrd.nhtsa.dot.gov/departments/nrd-11/childsafety/toc.htm (Accessed May 13, 2006).
7 American Academy of Pediatrics, Committee on Injury and Poison Prevention. Selecting and using the most appropriate car safety seats for growing children: guidelines for counseling parents. Pediatrics 1996;97:761–62.
8 Winston FK, Durbin DR, Kallan MJ, Moll EK. The danger of premature graduation to seat belts for young children. Pediatrics 2001;105:1179–83.
9 Stallard P, Salter E, Velleman R. Posttraumatic stress disorder following road traffic accidents—a second prospective study. Eur Child Adolesc Psychiatry 2004;13:172–78.[ISI][Medline]
10 Aitken ME, Tilford JM, Barrett KW et al. Health status of children after admission for injury. Pediatrics 2002;110:337–42.
11 Stallard P, Velleman R, Baldwin S. Prospective study of post-traumatic stress disorder in children involved in road traffic accidents. BMJ 1998;317:1619–23.
12 Corden TE. Analysis of booster seat and seat belt use: how many Wisconsin childhood deaths and hospitalizations could have been prevented in 1998–2002? World Med J 2005;104:42–45.
13 NHTSA. Booster seat study. Report to Congress. Washington, DC: US Department of Transportation, National Highway Traffic Safety Administration, 2002.
14 The Cochrane Collaboration. Review Manager [RevMan] Computer program Version 4.1 for Windows. Oxford, England: The Cochrane Collaboration, 2005.
Commentary: Interventions to increase booster seat use among 4–8 year olds
Department of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, London, UK
Road traffic crashes (RTCs) are a major cause of death and disability worldwide. By the year 2020 RTCs are predicted to become the third leading cause of disability-adjusted life years lost. A large proportion of the victims of RTCs are children. According to the WHO, in 2002 there were 1 80 500 children killed as a result of RTCs.1
For child occupants, booster seats have been shown to be an effective intervention for reducing injuries in the event of a road traffic crash, yet their use is limited and many children continue to be inappropriately restrained while travelling in motor vehicles.2 The systematic review by Ehiri et al.,3 which aims to evaluate the effectiveness of interventions to increase the use of booster seats, is therefore to be welcomed. The main conclusion of this high-quality review is that there are many effective interventions for increasing the use of booster seats among children, thus, offering valuable information for policy-makers.
Overall, the quality of the five included studies was high, with three studies having adequate allocation concealment. However, as the review authors acknowledge, there were some weaknesses limiting the quality of the evidence. There was limited measurement of confounders and three of the studies used self-reported outcome measures. One study, although conducted with a rigorous design (randomized, adequate allocation concealment and blinded), suffered from a high rate of loss to follow-up (34%).
There was marked heterogeneity between the studies and, although a random-effects model was used for the analysis, pooling of the study's results can still be problematic. Consequently, we should be cautious in the interpretation of the overall effect estimates. However, it is unlikely that this limitation would alter the review's main conclusions.
As it is acknowledged in the review, all the studies were performed in high-income countries, and, therefore, the findings should not be extrapolated to different settings.
Finally, it is important to emphasize that most RTCs occur in low-income and middle-income countries where the majority of the victims are not car users, but pedestrians.4 Future research should aim to obtain high-quality evidence for interventions, and policies to implement those interventions, for these most vulnerable RTC victims.
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1 Peden M, Scurfield R, Sleet D et al. World Report on Road Traffic Injury Prevention. World Health Organization, Geneva, 2004.
2 Ebel BE, Koepsell TD, Bennett EE, Rivara FP. Too small for a seatbelt: predictors of booster seat use by child passengers. Pediatrics 2003;111:e323–27.
3 Ehiri JE, Ejere HO, Magnussen L, Emusu D, King W, Osberg JS. Interventions for promoting booster seat use in four to eight year olds traveling in motor vehicles. Cochrane Database Syst Rev 2006;25:CD004334.
4 Ameratunga S, Hijar M, Norton R. Road-traffic injuries: confronting disparities to address a global-health problem. Lancet 2006;367:1533–40.[CrossRef][ISI][Medline]
Commentary: Interventions to increase booster seat use among 4–8 year olds
Child Accident Prevention Foundation of Southern Africa, Head Trauma Unit, Red Cross War Memorial Children's Hospital
Trauma continues to take a heavy toll on childhood health and according to the World Health Organization road traffic crashes will become the third leading cause of death in the near future.1 Young children and youth are the most vulnerable since they are neuro-developmentally immature and unable to assess dangers in their environment and/or act appropriately to avoid injuries.
This Cochrane Review of interventions for promoting booster seat use in 4–8 year olds travelling in motor vehicles discusses five randomized and controlled before-and-after trials investigating the effects of interventions to promote booster seats use in 3070 individuals. All interventions were found to have a positive effect. The objectives of this review are excellent, given the massive global problem of child deaths and injuries in motor vehicle crashes. In particular, since this study concerns 4–8 year old children, who are the most vulnerable, because they fall between the more accepted use of baby-seats for younger children and the safety belts use for adults. Unfortunately, booster seats for this age group are hardly available in non-Western countries, and, therefore, the their effect cannot be studied where it is most needed.
As the authors admit, this review of only five studies, all performed in the developed world (four USA, one Australia) suffers from bias towards high-income countries. Since 90% of child traffic deaths and injuries occur in the developing world, it remains unclear whether the study results can be translated to the developing world. The real challenge remains to decrease child injuries and deaths where they occur most commonly.
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1 Krug EG, Sharma GK, Lozano R. The global burden injuries. Am J Public Health 2000;90:523–26.
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