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Brown J, Keay L, Elkington J, Dai W, Ho C, Charlton J, Koppel S, McCaffery K, Hayen A, Bilston LE. User-driven instructions reduce errors in child restraint use: a randomised controlled trial in Sydney, Australia. Inj Prev 2024:ip-2023-045213. [PMID: 39327032 DOI: 10.1136/ip-2023-045213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 05/04/2024] [Indexed: 09/28/2024]
Abstract
BACKGROUND AND OBJECTIVES Crash injury risk is reduced when a child correctly uses an appropriate restraint; however, incorrect restraint use remains widespread. The aim of this study was to determine whether product information developed using a user-driven approach increases correct child restraint use. METHODS We conducted a two-arm double-blinded parallel randomised controlled trial in New South Wales, Australia 2019-2021. Participants were current drivers who were either an expectant parent or a parent of at least one child residing in the greater Sydney metropolitan area who were interested in purchasing a new child restraint. The intervention was user-driven product information consisting of instructions printed on an A3 sheet of paper, swing tags with key reminders and a video accessed via Quick Response codes printed on the materials. The control group received a postcard summarising legal child restraint requirements. The primary outcome was the correctness of child restraint use observed during home visit approximately 6 months after restraint purchase. Correct use was defined as no serious error or <2 minor errors. The secondary outcome was a count of observed errors. RESULTS 427 participants were recruited. Home visits were conducted for 372 (190 intervention and 182 control). Correct use was more common in the intervention group (37.4%) compared with the control group (24.2%, p=0.006). Participants receiving the intervention were 1.87 times more likely to correctly use their restraint than those in the control group (95% CI 1.19 to 2.93). CONCLUSIONS The results provide evidence for the effectiveness of user-driven instructions as a countermeasure to restraint misuse. TRIAL REGISTRATION NUMBER ACTRN12617001252303.
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Affiliation(s)
- Julie Brown
- The George Institute for Global Health, UNSW, Sydney, New South Wales, Australia
- Neuroscience Research Australia, Randwick, New South Wales, Australia
- The University of New South Wales, Sydney, New South Wales, Australia
| | - Lisa Keay
- The George Institute for Global Health, UNSW, Sydney, New South Wales, Australia
- The University of New South Wales, Sydney, New South Wales, Australia
| | - Jane Elkington
- The George Institute for Global Health, UNSW, Sydney, New South Wales, Australia
| | - Wennie Dai
- The George Institute for Global Health, UNSW, Sydney, New South Wales, Australia
| | - Catherine Ho
- The George Institute for Global Health, UNSW, Sydney, New South Wales, Australia
| | - Judith Charlton
- Monash University Accident Research Centre, Monash University, Clayton, Victoria, Australia
| | - Sjaan Koppel
- Monash University Accident Research Centre, Monash University, Clayton, Victoria, Australia
| | | | - Andrew Hayen
- University of Technology, Sydney, New South Wales, Australia
| | - Lynne E Bilston
- Neuroscience Research Australia, Randwick, New South Wales, Australia
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2
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Kendi S, Taylor MF, Thomas B, Khemraj UD, Mohamed MA, Macy ML, Chamberlain JM. Randomised feasibility trial of a virtual intervention to address infant car seat misuse. Inj Prev 2023; 29:29-34. [PMID: 36096654 PMCID: PMC10452043 DOI: 10.1136/ip-2022-044660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 08/21/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND Serious car seat installation errors occur at high rates in infants and children. These errors significantly increase the risk of child injury in a motor vehicle crash, and few interventions have addressed the challenge longitudinally. METHODS This was a pilot randomised controlled feasibility trial of virtual car seat safety checks for caregivers of newborns recruited from an urban newborn nursery. The control (enhanced usual care (EUC)) group received an in-person car seat check as a newborn and virtual check at 9 months. The intervention group received two additional virtual checks at 3 and 6 months. Installation and infant positioning errors were documented and corrected by a child passenger safety technician (CPST). We measured feasibility and acceptability by tracking caregiver and CPST challenges, and caregiver retention. Group differences were tested for statistical significance using χ2 or Fisher's exact test for categorical variables, and two sample t-tests for continuous variables. RESULTS 33 caregivers were randomised to the EUC and 28 to the intervention group. Virtual checks were feasible, with variable participation levels at each quarter. Wi-Fi and app challenges noted in 30%. There was satisfaction with the virtual car seat checks. At baseline, car seat installation and infant positioning errors occurred at equal frequency, and at 9 months the intervention group had a significantly lower mean proportion than the EUC group in all categories of errors. In summary, virtual seat checks are feasible and the optimal timing of repeat checks requires additional study. A larger study is needed to further evaluate the effect of longitudinal virtual checks on errors.
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Affiliation(s)
- Sadiqa Kendi
- Emergency Medicine, Children's National Health System, Washington, District of Columbia, USA
- Pediatric Emergency Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Michael F Taylor
- Emergency Medicine, Children's National Health System, Washington, District of Columbia, USA
| | - Bobbe Thomas
- Emergency Medicine, Children's National Medical Center, Washington, District of Columbia, USA
| | - Uma D Khemraj
- Pediatric Emergency Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | | | - Michelle L Macy
- Emergency Medicine, Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - James M Chamberlain
- Emergency Medicine, Children's National Medical Center, Washington, District of Columbia, USA
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3
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Kendi S, Taylor MF, Chamberlain J. Virtual car seat checks during a pandemic. Inj Prev 2020; 27:injuryprev-2020-044009. [PMID: 33272922 DOI: 10.1136/injuryprev-2020-044009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 11/12/2020] [Accepted: 11/16/2020] [Indexed: 11/04/2022]
Abstract
Motor vehicle collisions are one of the leading causes of death and morbidity in children and young adults in the USA, and suboptimal child restraint use is an important risk factor for severe childhood injury and death. The restrictions due to the COVID-19 pandemic have presented unique challenges to the public health community, including how to use certified child passenger safety technicians through car seat checks. This case series assessed the feasibility of performing remote car seat checks and parental satisfaction with them. It provides preliminary evidence that remote car seat checks are feasible in a real-world environment and acceptable to caregivers during times in which in-person car seat checks are not safe or accessible.
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Affiliation(s)
- Sadiqa Kendi
- Division of Pediatric Emergency Medicine, Children's National Health System, Washington, DC, USA
- Division of Pediatric Emergency Medicine, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
- Department of Pediatrics and Emergency Medicine, George Washington School of Medicine and Health Sciences, Washington, DC, USA
| | - Michael F Taylor
- Division of Pediatric Emergency Medicine, Children's National Health System, Washington, DC, USA
| | - James Chamberlain
- Division of Pediatric Emergency Medicine, Children's National Health System, Washington, DC, USA
- Department of Pediatrics and Emergency Medicine, George Washington School of Medicine and Health Sciences, Washington, DC, USA
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Brown J, Elkington J, Hunter K, Charlton JL, Bilston LE, Hayen A, Keay L. A Process Evaluation Protocol for Examining the Impact of Instructions for Correct Use of Child Car Seats Designed through a Consumer-Driven Process and Evaluated in a Field-Based Randomised Controlled Trial. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17124508. [PMID: 32585923 PMCID: PMC7345236 DOI: 10.3390/ijerph17124508] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 05/22/2020] [Accepted: 05/28/2020] [Indexed: 11/16/2022]
Abstract
The incorrect use of child car seats is common, with significant negative effects on crash protection for child passengers. There is currently little evidence for effective, practical countermeasures for incorrect use. The provision of clear and comprehensible materials on correct use supplied with restraints at the point of sale could be highly cost-effective and achieve similar benefits to restraint-fitting services or hands-on training; however, routinely supplied instructions in their current form are frequently difficult to understand. We are conducting a randomised controlled trial of the consumer-driven redesign of instructional materials, consisting of an instruction sheet, swing tags and online training videos. This paper presents the protocol that will be used in an innovate process evaluation that will use the primary outcome of overall serious misuse assessed at six months, together with a survey and semi-structured interviews to determine fidelity, dose and outcomes for all intervention participants. The study will assess intervention delivery and external factors that may impact the effectiveness of the intervention, including experience, health literacy, confidence and attitudes. When it has been conducted, this process evaluation will provide enhanced understanding of the mechanisms through which the intervention works or not, aspects of the implementation process key to success of the intervention and insight into how external factors influence the success of the intervention.
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Affiliation(s)
- Julie Brown
- The George Institute for Global Health, University of New South Wales, Sydney 2042, Australia; (J.E.); (K.H.); (L.K.)
- Neuroscience Research Australia (NeuRA) and Faculty of Medicine, University of New South Wales, Sydney 2031, Australia;
- Correspondence:
| | - Jane Elkington
- The George Institute for Global Health, University of New South Wales, Sydney 2042, Australia; (J.E.); (K.H.); (L.K.)
- Neuroscience Research Australia (NeuRA) and Faculty of Medicine, University of New South Wales, Sydney 2031, Australia;
| | - Kate Hunter
- The George Institute for Global Health, University of New South Wales, Sydney 2042, Australia; (J.E.); (K.H.); (L.K.)
| | - Judith L. Charlton
- Monash University Accident Research Centre, Monash University, Melbourne 3800, Australia;
| | - Lynne E. Bilston
- Neuroscience Research Australia (NeuRA) and Faculty of Medicine, University of New South Wales, Sydney 2031, Australia;
| | - Andrew Hayen
- School of Public Health, University of Technology Sydney, Sydney 2007, Australia;
| | - Lisa Keay
- The George Institute for Global Health, University of New South Wales, Sydney 2042, Australia; (J.E.); (K.H.); (L.K.)
- School of Optometry and Vision Science, University of New South Wales, Sydney 2052, Australia
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5
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Swanson M, MacKay M, Yu S, Kagiliery A, Bloom K, Schwebel DC. Supporting Caregiver Use of Child Restraints in Rural Communities via Interactive Virtual Presence. HEALTH EDUCATION & BEHAVIOR 2019; 47:264-271. [DOI: 10.1177/1090198119889101] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
When used correctly, child restraint systems (CRS) effectively reduce the risk of serious injury and death to child passengers in motor vehicle crashes. However, error rates in CRS use among caregivers are extremely high. Consultation with child passenger safety technicians (CPST) reduces misuse rates, but access to CPST is limited, particularly in rural areas. Remote consultation via interactive virtual presence (IVP) may increase access to CPST. One hundred and fifty caregivers in Southeast Montana completed remote consultation with CPST via IVP. Errors in CRS selection, installation, and child positioning were coded at baseline and postintervention in a within-subjects, pretest–posttest design. The proportion of caregivers making one or more errors in CRS selection (McNemar’s test p < .001) and installation (McNemar’s test p < .001), but not child positioning, significantly decreased following remote consultation. IVP is a promising mobile health (mHealth) strategy for providing remote consultation with CPST to improve rates of correct CRS use and mitigate child injury risk.
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Affiliation(s)
| | | | | | | | - Koren Bloom
- Safe Kids Yellowstone County, Billings, MT, USA
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Schwebel DC, MacKay JM, Redden D. Study protocol: a randomised non-inferiority trial using interactive virtual presence to remotely assist parents with child restraint installations. Inj Prev 2019; 26:289-294. [PMID: 31727672 DOI: 10.1136/injuryprev-2019-043463] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 10/08/2019] [Accepted: 10/14/2019] [Indexed: 11/03/2022]
Abstract
BACKGROUND Motor vehicle crashes are the third-leading cause of death to American children aged 1-5 years. When installed correctly, child restraints (car seats) reduce risk of serious injury and death. However, most restraints are installed incorrectly. The current gold standard for correct installation is systematic car seat checks, where certified technicians help parents, but car seat checks are highly underused due to barriers in access, scheduling and resources. METHODS The present study protocol describes plans to evaluate use of interactive virtual presence technology (interactive merged reality)-joint, simultaneous remote verbal and visual interaction and exposure to the same 3D stimuli-to assist remotely located parents installing child restraints. If effective, this technology could supplement or replace in-person checks and revolutionise how government, industry and non-profits help parents install child restraints properly. Building from preliminary studies, we propose a randomised non-inferiority trial to evaluate whether parents who install child restraints while communicating with remote expert technicians via interactive virtual presence on their smartphones achieve installations and learning not inferior in safety to parents who install restraints with on-site technicians. We will randomly assign 1476 caregivers at 7 US sites to install child restraints either via interactive virtual presence or live technicians. Correctness of installation will be assessed using objective checklists, both following installation and again 4 months later. CONCLUSION We aim to demonstrate that child restraint installation is accurate (>90% correct) when conducted remotely, that such installations are not inferior to installation accuracy with live experts and that parents learn and retain information about child restraint installation.
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Affiliation(s)
- David C Schwebel
- Psychology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | - David Redden
- Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Glerum KM, Zonfrillo MR, Fleisher L, McDonald CC. Systematic review of child restraint system interventions (2007-2018). TRAFFIC INJURY PREVENTION 2019; 20:866-872. [PMID: 31725324 DOI: 10.1080/15389588.2019.1666372] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Revised: 07/22/2019] [Accepted: 09/07/2019] [Indexed: 06/10/2023]
Abstract
Objective: To systematically review and summarize articles evaluating the effectiveness of child restraint system (CRS) interventions targeting parents/caregivers' knowledge of, overall rates of and/or proper use of CRSs published in a recent time period.Methods: Using multiple databases, we identified peer-reviewed journal articles published between January 1, 2007 and December 31, 2018 using selected key search terms. Inclusion criteria were: (1) evaluation of an intervention/program for child passenger safety targeting a parent or caregiver of a child (2) quantitative data-based results (i.e., change in knowledge, behavior, or observed outcomes), (3) English-language, and (4) peer-reviewed journal publication. Through a systematic review process and peer consensus, n = 23 articles met inclusion criteria. References of these articles were reviewed for inclusion using the same process and n = 12 additional articles were identified.Results: A total of n = 35 articles met inclusion criteria. Of the n = 35 articles, n = 9 were randomized controlled trials (RCTs), n = 4 were cluster RCTs, n = 11 were nonrandomized trials, and n = 11 were pretest post-test studies. Types of interventions included face-to-face education (n = 26), web/video-based education (n = 8) or written educational materials (n = 1). Of the articles reviewed, n = 20 involved distribution of free or subsidized CRSs to some or all subjects. N = 20 articles involved trained CRS technicians and/or CRS installation check-points. In terms of outcomes measured, n = 3 articles assessed changes in knowledge of CRS use, n = 22 assessed changes in CRS behaviors (which includes self-report or observed behavior change), and n = 10 assessed changes in both CRS knowledge and behaviors. All articles (n = 3) that measured changes in knowledge as their only outcome demonstrated positive effects while articles measuring behavioral outcomes (self-report or observed) (n = 32) had mixed results.Conclusions: This review included a wide range of articles of heterogeneous methodologies, sample sizes, and outcomes measured. Although different approaches to CRS interventions were effective in increasing awareness and knowledge, the effects on CRS use behaviors - whether self-reported or observed - were mixed. Future research is needed to increase appropriate CRS use and reduce the burden of motor vehicle crash-related injuries among children.
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Affiliation(s)
- Kimberly M Glerum
- The Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Mark R Zonfrillo
- Departments of Emergency Medicine and Pediatrics, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Linda Fleisher
- Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Catherine C McDonald
- Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
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8
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Hall AB, Ho C, Albanese B, Keay L, Hunter K, Charlton J, Hayen A, Bilston LE, Brown J. User-driven design of child restraint information to reduce errors in use: a pilot randomised controlled trial. Inj Prev 2019; 26:432-438. [PMID: 31530570 DOI: 10.1136/injuryprev-2019-043380] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 08/18/2019] [Accepted: 08/19/2019] [Indexed: 11/03/2022]
Abstract
BACKGROUND Incorrect use of child restraints is a long-standing problem that increases the risk of injury in crashes. We used user-centred design to develop prototype child restraint instructional materials. The objective of this study was to evaluate these materials in terms of comprehension and errors in the use of child restraints. The relationship between comprehension and errors in use was also explored. METHODS We used a parallel-group randomised controlled trial in a laboratory setting. The intervention group (n=22) were provided with prototype materials and the control group (n=22) with existing instructional materials for the same restraint. Participants installed the restraint in a vehicle buck, secured an appropriately sized mannequin in the restraint and underwent a comprehension test. Our primary outcome was overall correct use, and our secondary outcomes were (1) comprehension score and (2) percent errors in the installation trial. RESULTS There was 27% more overall correct use (p=0.042) and a higher mean comprehension score in the intervention group (mean 17, 95% CI 16 to 18) compared with the control group (mean 12, 95% CI 10 to 14, p<0.001). The mean error percentage in the control group was 23% (95% CI 16% to 31%) compared with 14% in the intervention group (95% CI 8% to 20%, p=0.056). For every one point increase in comprehension, there was an almost 2% (95% CI -2.7% to -1.0%) reduction in errors (y=45.5-1.87x, p value for slope <0.001). CONCLUSIONS Consumer-driven design of informational materials can increase the correct use of child restraints. Targeting improved comprehension of informational materials may be an effective mechanism for reducing child restraint misuse.
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Affiliation(s)
- Alexandra B Hall
- Neuroscience Research Australia, University of New South Wales, Sydney, New South Wales, Australia
| | - Catherine Ho
- Neuroscience Research Australia, University of New South Wales, Sydney, New South Wales, Australia
| | - Bianca Albanese
- Neuroscience Research Australia, University of New South Wales, Sydney, New South Wales, Australia
| | - Lisa Keay
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Kate Hunter
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Judith Charlton
- Accident Research Centre, Monash University, Clayton, Victoria, Australia
| | - Andrew Hayen
- Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Lynne E Bilston
- Neuroscience Research Australia, University of New South Wales, Sydney, New South Wales, Australia
| | - Julie Brown
- Neuroscience Research Australia, University of New South Wales, Sydney, New South Wales, Australia .,The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
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Macy ML, Kandasamy D, Resnicow K, Cunningham RM. Pilot Trial of an Emergency Department-based Intervention to Promote Child Passenger Safety Best Practices. Acad Emerg Med 2019; 26:770-783. [PMID: 30637887 PMCID: PMC6626697 DOI: 10.1111/acem.13687] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 12/19/2018] [Accepted: 12/26/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Despite demonstrated effectiveness of child restraint systems (CRSs), use remains suboptimal. In this randomized pilot trial, we sought to determine the feasibility, acceptability, and potential efficacy of "Tiny Cargo, Big Deal" an ED-based intervention to promote guideline-concordant size-appropriate CRS use. METHODS Parents of children < 11 years old were recruited in two EDs and randomized in a 2 × 2 factorial design to four conditions: 1) generic information sheet, 2) tailored brochure mailed after the ED visit, 3) a single motivational interviewing-based counseling session in the ED, and 4) full intervention (counseling session plus tailored brochure). We assessed feasibility (recruitment, completion, follow-up rates) and acceptability (parent attitudes, uptake of information) in the ED, at 1 month and at 6 months. We obtained preliminary estimates of effect sizes of the intervention components on appropriate CRS use at 6-month follow-up. RESULTS Of the 514 parents assessed for eligibility, 456 met inclusion criteria and 347 consented to participate. Enrolled parents were mostly mothers (88.1%); 48.7% were 18 to 29 years old; 52.5% were non-Hispanic, white; and 65.2% reported size-appropriate CRS use. Completion rates were 97.7% for baseline survey, 81.6% for counseling, 51.9% for 1-month follow-up, and 59.3% for 6-month follow-up. In the ED, 70.5% rated thinking about child passenger safety in the ED as very helpful. At 1 month, 70.0% expressed positive attitudes toward the study. Of 132 parents who reported receiving study mailings, 78.9% reviewed the information. Parents randomized to the full intervention demonstrated an increase (+6.12 percentage points) and other groups a decrease (-1.69 to -9.3 percentage points) in the proportion of children reported to use a size-appropriate CRS at 6-month follow-up. CONCLUSIONS Suboptimal CRS use can be identified and intervened upon during a child's ED visit. A combined approach with ED-based counseling and mailed tailored brochures shows promise to improve size-appropriate CRS use.
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Affiliation(s)
- Michelle L. Macy
- Department of Emergency Medicine, Michigan Medicine, Ann Arbor, Michigan; The Child Health Evaluation and Research (CHEAR) Center, Division of General Pediatrics, University of Michigan, Ann Arbor, Michigan; The University of Michigan Injury Prevention Center, Ann Arbor, Michigan; Current affiliation: Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL;
| | - Deepika Kandasamy
- The Child Health Evaluation and Research (CHEAR) Center, Division of General Pediatrics, University of Michigan, Ann Arbor, Michigan; Current affiliation: Department of Emergency Medicine, University of Colorado-Denver, Aurora, Colorado;
| | - Ken Resnicow
- School of Public Health, University of Michigan, Ann Arbor, Michigan;
| | - Rebecca M. Cunningham
- Department of Emergency Medicine, Michigan Medicine, Ann Arbor, Michigan; The University of Michigan Injury Prevention Center, Ann Arbor, Michigan; School of Public Health, University of Michigan, Ann Arbor, Michigan;
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