Safe Kids Checkup Events: A National Study by Safe Kids Worldwide

Safe Kids Checkup Events: A National Study February 2007

Introduction Motor vehicle crashes are the leading cause of death to children ages 3-141 and the leading cause of injury death for children under age 3.2 Since 1996, Safe Kids Worldwide has partnered with General Motors to provide child passenger safety education targeted to caregivers and parents at the community level. The program promotes correct child restraint use and increases awareness about the benefits of keeping children in child restraints for as long as possible. Safe Kids events are held at GM and Chevrolet dealerships, hospitals, retail outlets and other community venues to provide as much local exposure as possible. A checkup event allows a parent/caregiver to work one on one with a certified child passenger safety technician in their own vehicle with a child present. The message given to all parents at all Safe Kids events is to keep children appropriately restrained for their age, weight and height. A standardized checklist is used for documentation. Safe Kids Worldwide developed the checklist in the late 1990s to be used for all grant-funded activities. The checklists have been used to assist manufacturers in addressing areas of repeated misuse so the product can be re-engineered appropriately. The checklist provides a guided, standardized tool for car seat technicians to ensure that they have addressed key safety components with parents and caregivers. The objective of this study was to measure parent confidence levels, skill development and safe behavior over a six-week interval using the checklists and a matching behavioral survey.

Child Passenger Safety Background

Positive Study Results

The adult safety belt system alone becomes suitable for children when they are approximately 4'9" tall and weigh 80 to 100 pounds, a milestone the average child reaches between the ages of 8 and 12. For infants and children too small to safely use the adult safety belt system, child restraints such as child safety seats and belt-positioning booster seats offer the best crash protection.

Study results show that within the six-week time period, the CPS Week 2005 child passenger safety checkup events successfully and positively changed parents’ behavior and increased their knowledge: Children arriving at event 2 were restrained more safely and more appropriately than they were at event 1.

Properly used child safety seats decrease the risk of death by 71 percent for infants and 54 percent for toddlers. Injury risks for children using belt-positioning booster seats are reduced by 59 percent.3

Study Methodology

Event 1

Event 2

Appropriate seat selection

n=335

78%

96%

Harness correct

52%

83%

Seat tight

45%

84%

Harness snug

43%

80%

Safety belt routed correctly

89%

98%

Average misuse rate

19%

Children arrived unrestrained

<1%

This report highlights the results of child passenger safety checkup events held in 29 states. Each coalition hosted two events held six weeks apart. The first event took place during Child Passenger Safety (CPS) Week, February 13–19, 2005, and the second checkup took place before April 20. The goal of the research was to assess whether the events’ educational efforts increased participants’ knowledge, skills and abilities with regard to child passenger safety. Safe Kids Worldwide coalitions were asked to take part in the study through a weekly e-newsletter; 48 coalitions in 29 states were included in this study. Each coalition selected at least two certified CPS technicians to conduct the research. Parents and caregivers were asked at the first event to take part in the study and commit to returning for the second event with the same child. The study had two components: a survey, completed by parents and caregivers, that measured their understanding of proper CPS practices, and a Child Passenger Checklist completed by the CPS technician that recorded child safety seat (CSS) use and misuse. The checklist evaluated the participant’s CSS installation errors and the seating position of the child in the vehicle. The survey and a checklist were filled out at both events. At the first event, parents were taught to properly install the child restraint after the technician completed the evaluation and checklist. They also learned how to choose the most appropriate CSS based on the child’s age, height and weight and how to safely secure their child in the CSS. Technicians answered questions from parents at that time. They also gave parents literature about CPS practices and strongly encouraged them to register the CSS or booster seat with the manufacturer. Technicians checked the CSS for recalls, expiration dates and obvious damage. Finally, technicians made sure that the parent installed the seat and secured the child so the lesson was not simply a demonstration. To ensure that no child leaves a checkup event improperly restrained, Safe Kids coalitions generally have replacement seats available for families with damaged or old seats. At the second event, parents were asked to remove the CSS, reinstall it on their own and secure the child in the seat before the technician evaluated the installation using the standardized checklist. Parents then took the knowledge survey again. The surveys and Child Passenger Checklists from both events were sent to an independent research firm for analysis.† 2

Parents’ Survey Results Three hundred thirty-five sets of surveys from parents or caregivers who attended both checkup events hosted by the 48 coalitions were analyzed. Child Passenger Checklists were completed by CPS technicians for 321 children who were present at both events, a total of 642 checklists. The study looked at 279 children in rear-facing seats, 242 in forward-facing seats, 98 in booster seats, seven in safety belts, one in a shield/laptop booster, and 15 unrestrained children at the two events. Nanny/Babysitter 1% Grandparent 12%

Grandparent 12% Father 19%

The U.S. population has the following racial makeup: white Missing Data 5% Nanny/Babysitter 1% (including Hispanic), 81.7 percent; black, 12.9 percent; Grandparent 12% Male 22% Asian, 4.2 percent; American Indian and Alaska native, 1 percent; and native Hawaiian and other Pacific Islander, 0.2 Father 19% percent (2003 estimate).5 Hispanics make up 14.5 percent of the population.6 Since 5 percent of event attendees were black and 7 percent were Hispanic, the events underrepresented the United States’ racial/ethnic makeup. Missing Data 5% Missing Data 5% Graduate Degree or Higher 15% Male 22%

Seventy-two percent of those who attended the events had at least some college education. According to the 2005 American Community Survey, only 46.4 percentCollege of Graduate 30% American adults have attended college.7

67% Mother What was the gender of the caregiver at the event? (n=335)

1% Aunt/Uncle

Racial makeup of parents 67% andMother caregivers at 73% theFemale events (n=335)

Father 19%

1% Aunt/Uncle 67% Mother

67% Mother

100%

Missing Data 5% HIspanic 7% Missing Black 5%Data 5% Nanny/Babysitter 1% Male 22% Grandparent 12% Missing Data 5% Father 19% Male 22%

80% Missing Data/ Hispanic 60% Missing Black 5 HIspanic 40% Missing Data Black 5 20% Hispanic Black 0%

1% Aunt/Uncle 83% White 73% Mother Female 67%

73% Female

MissingMissing Data/Other Data 6% 5% Hispanic HIspanic 7% 7% Missing Data 5% Black 5% Black 5% Graduate Degree Missing Data 5% or Higher 15% Missing Data 5% Male 22% Graduate Degree College or Higher 15% Graduate 30% College Graduate 30%

4% High School Missing Data/Other Age 6 2% 6% or Less Hispanic Age 5 7% 5% Black 5% Age 4 7% 19% High School Missing Data 5% Graduate Age 3 10% Graduate Degree or Higher 15% 73% Female Age 2 10% 27% Some College College Graduate 30%

Educational attainment of attendees (n=335)

Number of Parents/Caregivers

1% Aunt/Uncle

Nanny/Babysitter 1% Father 19% Grandparent 12%

80% 60 4% High School A or Less 60% 40 Missing Age Data/O 5 Hispanic Age 40% 4 20 7 19% High School 81% White 4%White High School Black 5A 83% Graduate Age 3 10 20% or Less Age 5 Age 40% 19% High School Graduate Age 2 73% Female 27% Some College Age 3 1 27% Some College

2% Age 7 4% High School or Less 81% Age White<1 42% 19% High School Graduate 22% Age 1 27% Some College

Children Ninety-one percent of children whose caregivers completed Missing Data 5% Graduate the survey were ages 0 to 4 — the group most likely to Degree or Higher 15% still be riding in a CSS with a harness. Eighty-three percent weighed less than 40 pounds. College Graduate 30%

4% High School or Less 19% High School

Graduate of Total percent child attendees for event 27% 1 (n=335) Some College

Age 6 2% Age 5 5% Age 4 7% Age 3 10%

100

100% 80

2% Age 7

42% Age <1

Age 2 10% 22% Age 1

Most parents and caregivers said they attended the event to “be sure everything is OK” or because they “just got a new car seat.” Only a few said they wanted to change the direction of their child’s seat or had recently bought a new vehicle. They said they found out about the event (in descending order) via newspaper/radio/TV, friend/relative, other, drove by the dealership, flyer and Internet.

Age 2 Number of Children/Parents Number of Parents/Caregivers who Sometimes Ride Unrestrained

Nanny/Babysitter 1%

Who was the caregiver at the event? (n=335)

100

Number of Children/Parents Number of Parents/Caregivers who Sometimes Ride Unrestrained

Mothers made up the majority of the caregivers who came to the events, followed by fathers and grandparents. The number of women who brought children to the events was more than three times higher than the number of men. Men/ fathers were therefore less likely to attend a checkup event and receive the vehicle safety event information.

Educational attainment

Missing HIspanic Black 5 Missing HIspanic Black

1% Aunt/Uncle

250

80 100 60 80 A 40 60 Age 5 20 40 Age 4 7 0 Age 3 20 10 0

Age 2 1

Number of Parents/Caregivers

DEMOGRAPHICS

200

100 150

80 100

60 50

400

250

200

150

100

Number of Childre who Sometimes Ride

Number of Parents/Caregivers

250

Event 1, n=53 Unrestrained 4% Safety Belt 13%

0 BOOSTER KNOWLEDGE Event 1, n=335

Shield Booster or Laptop 2%

Event 2, n=335

CSS Choice for Children Who Were > 1 Year and 40 to 79 Pounds Belt-Positioning

When a child weighs 40 to 80 pounds, what type of restraint will protect him or her best? 226

246

Event 1, n=335 Event 2, n=335

200 150 100 50 0

19 8

Rear-Facing FrontInfant Seat Facing Seat

Booster 49%

Event 1, n=53 Unrestrained 4% Safety Belt 13%

32% Forward-Facing

11 9

Belt-Positioning Booster 49%

Booster Adult Missing Seat Safety Belt Data

Event 2, n=61

ForwardFacing 8%

Shield Booster or Laptop 2%

74 67

32% Forward-Facing

Belt-Positioniong Booster 92%

Event 2, n=61

Percent of Seats for which the History Is Known

ForwardMany parents correctly knew that children who weighed 40 to 80Facing pounds should be in a booster seat at event 1;100 8% however, even more parents were able to answer this question correctly by event 2. According to the checklists, fewer than 50 percent of parents with a child in this age group arrived at the event using a booster seat. This number rose 98% 100 seat, 90% considerably by the second event, and although 8 percent still rode in a forward-facing harness no booster- 90 Belt-Positioniong appropriate children arrived unrestrained or in an adult safety belt. Booster 92%

CONFIDENCE LEVELS AND PARENT INVOLVEMENT IN SEAT INSTALLATION

Number of Parents/Caregivers

40100 20 80 0 60

Not Somewhat Pretty Very 40 Confident Confident Confident Confident

20 0

Somewhat Involved Very Involved Not At All Involved Very Involved Somewhat Involved Somewhat Involved Not At All Very Involved Involved Not At All Involved Somewhat Involved Not At All Involved Very Involved

20Not Somewhat Pretty Very Confident Confident Confident Confident 0 Not Somewhat Pretty Very Confident Confident Confident Confident

Number of Children/Parents nts/Caregivers who Sometimes Ride Number of Unrestrained Children/Parents of Parents/Caregivers Sometimes Ride Unrestrained Number of who Children/Parents egivers who Sometimes Ride Unrestrained

4% High School

Age 6 2% 2% Age 7 The ornumber of parents who reported that they sometimes Less Age 5 5% allow their children to ride unrestrained decreased by the Age Age 4 7% 4% High School 19% High School 6 2% 2% Age 7 second of parents who reported that they orGraduate Lessevent. The number Age Age53 5% 10% ride unrestrained also went down, although that number 4% High School Age 4 7% Age 6 2% 2%42% Age 7 19% High School Age <1 or Less for parents Age Graduate 5 5% stayed higher than for children at both events. Age 3 10% Age 2 10% 27% 19% SomeHigh College Age 4they 7% and their children School While parents learned that 42% should Age <1 Graduate Age 3 10% always buckle up, many don’t always practice this behav22% Age 1 Age 2 10% 27% Some College Age <1 ior. The most frequent reason given at both events 42% for not 22% traveled. Age 1 restraining children to do with the distance 2 10% 27% Some College had Age Parents were less likely to buckle up their children for short 22% Age 1 trips or drives on local roads.

Somewhat Involved Not At All Involved

Kids Sometimes

100

How often do79 you allow your children to ride Parents Sometimes 80 unrestrained? How often do you ride unrestrained? Kids Sometimes 100 80 60 40 20

40100 20 80 50 0 60

250

Event50 1, n=335

Event 2, n=335 14 38 Event 2,14 n=335

20 Event 1, n=335 0

200 250 150 200 100250 150 50200

Parents Sometimes 38 Kids Sometimes Parents Sometimes 38

226 Event 1, n=335 226 74 67

246

246 226

Event 2, n=335Event 1, n=335 Event 2, n=335

246

Event 1, n=335 Event 2, n=335 Event 1, n=335 Event 2, n=335

Event 2

RESTRAINT USE FREQUENCY

Somewhat Involved

At All Involved VeryNot Involved

Event 1

81% White

Very Involved

Rear-Facing 98%

Event 2

73% Female

in Seat Installation (n=335)

Event 2

73% Female

81% White

Unrestrained 6% Forward-Facing 6%

80% Event 1 100% Event 2 60% 50 80% Event 1 87% Rear-Facing 40% 40% 32% 32% 100% 26% 23% Event 2 60% 19% 18% 20% 80% Event 1 40% 7% 0 40% 32% 32% 26% 0% Yes Event 2 60% 23% 19% Somewhat Pretty 40% Very 20% 18% Not 7% 40% Confident Confident Confident Confident32% 32% 26% 0% 23% 19% 18% Event 2 20% Not Somewhat Pretty Very 7% <1 Year and < 20 Po Confident Confident Confident Confident 0% Somewhat Pretty Very Involvement ConfidenceNot Levels and Self-Reported Forward-Facing 2% Confident Confident Confident Confident 100 100

81% White

90%

100 100%

Event 1

<1 Year and < 20 Po

Event 1, n=298 Event 2, n=319

98%

Event 1

73% Female

Hispanic 7% Black 5% Missing Data/Other 6% Hispanic 7% Black 5%

Event 1 n=321

Event 1

Missing Data/Other 6% Hispanic 7% Black 5% 6% Missing Data/Other

Percent of Seats for which the History Is Known

Missing Data 5%

1% Aunt/Uncle

HIspanic 7% At the second event, parents who said they were “very 67% Mother Black Missing 5% Data 5% 83% White involved” or “somewhat involved” in the installation of the 1% Aunt/Uncle HIspanic 7% seat were more confident in their ability to install the seat. Black 5% 67% Mother 83% White The rise in overall confidence levels shows that parents benMother efited 67% from the education they received at the first event. In 83% White addition, the more involved parents were in installing the seat, the more confident they were in their ability to do so.

0 Parents’ and Caregivers’ Confidence Levels (n=335) Yes

Number of Parents/Caregivers Number of Parents/Caregivers

More parents self-reported as “pretty confident” or “very confident” about their ability to correctly install the safety Missing Data their 5% child in the seat at the seat their vehicle and secure 1%in Aunt/Uncle HIspanic 7% second event than theyBlack were at the first event. 5%

Event 1, n=29 Event 2, n=31

Booster 49%

Event 2, n=61

Event 1, n=53

CHILD SAFETY SEAT MISUSE SELECTION) Unrestrained(SEAT 4% Safety Belt 13%

32% Forward-Facing

ForwardFacing 8%

Percent of Seats for which the History Is Known

Belt-Positioniong Booster 92%

Percent of Seats for which the History Is Known

80 60% 40% 90

The average error rate was reduced by approximately 10 percentage points for each type of child restraint from event 1 to event 2, showing that parents were able to retain the information they learned about installation over a six week period.

57% Event 1 n=321

100% 80%

Event 1, n=298Age > 1 and Event 2, n=319Age <1 YearUnrestrained and < 20 lbs. 6% Age > Forward-Facing 1 and Weight 20 to6% 39 lbs.

60%

Event 2 n=321 22%

40% 20%

Rear-Facing 87%

20%

Event 1

CSS Choice for Children Who Were No < 1 Year and < 20 Pounds

<1 Year and < 20 Pounds, n=111 80 Event 1Yes Event 2 Yes Unrestrained 6% n=321 n=321

Forward-Facing 6%

Event 1

Event 2

<1 Year and < 20 Pounds, n=111

<1 Year and < 20 Pounds, n=123

99%

Rear-Facing 87%6%96% Unrestrained 100%

100%

Event 1, n=292 Event 2, n=315

Forward-Facing 2%

Forward-Facing 6%

80%

60% Rear-Facing 87%

80%

60%

Rear-Facing 98%

40%

40% 20%

20%

4% 1% 0% <1 Year and < 20 Pounds, n=123 Yes No/Unable to Determine

Yes

CHILD SAFETY SEAT MISUSE (ERROR RATE)

Age > 1 and W Age <1 Year anE Age > 1 and W

100

Event 1, Event n=2851 <1 Year and < 20 Pounds, n=111 Event 2, n=310 Weight 40 to 79 lbs.

86%

80% 98% 90%100

Children younger than 1 and weighing less thanEvent 20 pounds 1, n=2980 98% 100 event in90% arrived at the first the correct rear-facing safety seat Event 2, n=319 87 percent of the time. Because parents are often eager to prematurely switch their children to forward-facing seats, Event 1, n=298 98% the drop from 6 50 percent 100 to 2 percent 90% of infants arriving Event 2, in n=319 forward-facing seats from event 1 to event 2 shows that this small group of parents learned that a rear-facing seat is the 0 50 safest way to travel with an infant. No infants arrived unreYes strained at the second event.

Not Somewhat Confident Confident C

Age > 1 and Weight 40 to 79 lbs. 0 < 20 lbs. Age <1 Year and Not Somewhat Pretty Very Age > 180and Weight 20 to 39 lbs. Confident Confident Confident Confide Event 1 Event 2 n=321 n=321

100

90 100% 100

Percentage of Children in the Correct CSS Choice by Age/Weight90 50

Event 2, n=61 ForwardFacing 8%

150

100

More than 80 percent of parents had their children in the Shield BoosterEvent 2, n=61 correct CSS at the first event, or Laptop 2% and those numbers rose sigForwardnificantly to more Facing than 8% 95 percent at the second event.Belt-Positioniong Also, Booster 92% Belt-Positioningat the first event while only 14 children arrived unrestrained Booster 49% one child arrived unrestrained at the second event. Belt-Positioniong Booster 92%

Number of Parents/Caregivers

Belt-Positioning Booster 49%

Number of P

or Laptop 2%

Event 2

Forward-Facing <12% Year and < 20 Pounds, n=123 Forward-Facing 2%

Rear-Facing 98%

Misuse Rates by Restraint Type

100% Rear-Facing 98%

The error rate indicates the percentage of errors made out of the total errors possible for a particular seat type. For example, a rear-facing seat has 15 possible error types listed on the checklist. If a seat arrives with five errors, then the error rate is 5/15, or 33 percent. If a rear-facing seat does not have a carrying handle, for example, that element would be marked as not applicable and the error rate would be 5/14, or 36 percent. Similarly, if a child is not present during the fitting and five harness elements cannot be assessed, the error rate would be 5/10, or 50 percent.

Event 1, n=275 Event 2, n=320

93%

100% 80%

80%

60% 40%

60%

20% 40% 20%

0% 19%

16% 7%

Rear-Facing Infant Seat

6% ForwardFacing Seat

13% 3% BeltPositioning Booster

0% Safety Belt

100% 80% 60% 40%

Best-practice recommendations for seat typeS

20%

• Children should be restrained in a rear-facing CSS until they are at least 1 year old and weigh 20 pounds, although current best practices suggest using the rear-facing convertible CSS for as long as possible following the weight and height limits set by the manufacturer.

• Children who are ages 1 or older and weigh 20 to 40 pounds should ride forward facing in a harnessed CSS. • Children should ride on a booster seat until they are at least 8 to 12 years old, weigh 80 to 100 pounds and are up to 4 feet 9 inches tall. • Children taller than 4 feet 9 inches who weigh between 80 to 100 pounds may ride restrained in adult safety belts. • Always refer to the CSS instruction manual for exact weight and height guidelines.

40%

20%

22%

20%

40% 20% 4% 1% 0% No/Unable to RearDetermine Facing

CHILD SAFETY SEAT INSTALLATIONYes Yes No Percentage of Seats With Correct Safety Belt Routing 99%

96% 100%

80%

90%

98%

97%

88%

90%

80%

100% 1, n=292 Event 1, n=254 Event 2, n=315 Event 2, n=305 80%

100%

Event 97%

60%

40%

20%

60%

Yes

RearFacing

Forward-

85%

40% Belt-

Facingto Determine Positioning No/Unable Booster20%

20%

Correct Tether Use

Event 1, Event n=2751, n=46 Event 2, Event n=3202, n=41

100%

Event 1, n=280 Event 2, n=269

83%

80% 60% 100% 54%

43%

80% 60%

0%40%

Correct

13%

80%

40% correctly

40%

80%

0% 1%

1% 1%

20% 2% 0%

20%

When the

The Child

The Child’s Car

81% 78%

Don’t

E E

80%

AlthoughCorrect many parents were using the safety belts at event 1, close to 100 percent of all safety belts were correctly 20% 60% 51% 9%anchors were installed60% 20% lower 48% routed at event 2. Less than 50 percent1% of 1% all seats using correctly; by 3% 3% 46% 2% 42% correct use doubled 0% 1% 0% When the The Child The Child’s Car Don’t Missing 40% 2.40% 0% event 2. Twenty-nine percent more parents showed proper use of the top tether by event Seat Belt is Cannot Seat Does Not Correct Know Data

60%

40% 16%

Buckled Through the Car Seat

19%

Touch His Toes

Move From Side to Side More Than One Inch

13% Event 1, n=280 CAR SEAT REGISTRATION, LABELS AND HISTORY 6% 83% 2, n=269 3% Event 0% 0% 100% 54% event, 60%the Rear-Facing ForwardBelt- 57 percent Safety At first of parents and caregivers 80% 78% Infant Seat Facing Positioning Belt 80% 40% said they completed and mailed the registration card, Seat had Booster 60% 51% 20% and 86 percent said they had done so at48% the second event. 40% 0% Returning registration cards is important so that car seat Correct 100% 20% 100% 7% 80%

manufacturers know whom to contact in case of a recall. 81% 0% 80% Rear-Facing Forward-Facing Technicians often mail the cards in for seats distributed at 60% the events, contributing to the positive results at event 42% 2. Event 1, n=226 Event 2, n=253

100%

81%

80% 60% 40%

86%

42%

40% 20% 0%

Rear-Facing

46%

Ninety-six percent of the seats that arrived at the first event were labeled as meeting federal standards, while 99 percent 0% Rear-Facing of the seats at theForward-Facing second event were found to meet those standards. “Unable to determine” most likely meant that the stickers or expiration date on the seat were missing or badly faded.* At the second event, less than 1 percent of seats either failed to meet federal standards or technicians were unable to determine their compliance. This may have been due to the distribution of replacement seats at the first event, another positive feature of the checkup events. * The Juvenile Products Manufacturers Association recommends a shelf life

20%

0% Rear-Facing Rear-Facing

Forward-Facing Forward-Facing

Percentage of Safety Seats for Which Caregivers Indicated the Registration Form Event 1, n=226 Had Been Completed and Returned Event 2, n=253

Event 1, n=172 Event 2, n=223

100%

86%

100

Event 1, n=285 Event 2, n=310 Event 1, n=285 Event 2, n=310

86%

80 100% 60 80% 40 60% 20 40% 0 20%

80% 100% 86% 57% 60% 80% 46% Event 1, n=53 40% 57% 60% Unrestrained 22% 4% 20% Safety Belt 13% 32%6% Forward-Facing 40% 22% 0% 20% Forward-Facing No 6% Shield Booster Yes 0% or Laptop 2% Yes No

Percentage of Safety Seats Labeled Federal Standards

Belt-Positioning 99% as Meeting 96% 49% 100%Booster 80% 100% 60% 80% 40% 60% 20% 40% 0% 20%

99%

96%

Event 2, n=61 ForwardFacing 8%

80 100 60 80 40 60 100 20 40 0 20

Yes

No/Unable 4% to Determine 1%

Yes Belt-Positioniong Booster 92%

No/Unable to Determine

100

Event 1, n=292 Event 2, n=315 Event 1, n=292 Event 2, n=315

80 100%

safety seats should be replaced after a moderate or severe crash to ensure a continued high level of protection for child passengers.9

93%

Is the CSS’ original owner and history 100% 93% 80%

80% 60%100 60% 40% 40% 20%

Event 1, n=275 Event 2, n=320 known? Event 1, n=275 Event 2, n=320

Event 1, n=298 Event 2, n=319

98%

90%

100

80 100% 60 80% <1 40 60% Unrestrained 206 Forward-Facing 40%

0 20%

19%

16% 7%

Seat ForwardFacing Seat

Rear-Facing 87% 0%

13%

19% 3% 20% 16% 0% 0 13% Rear-Facing ForwardBelt7% 6% Yes Positioning 3% Facing 0% Infant Seat Rear-Facing Infant Seat

of six years for child safety seats.

Safe Kids Worldwide recommends that parents use safety seats with known histories to ensure that they were never involved in a crash. At event 2, 44 more parents/caregivers were able to say they knew the history of their seat. This was in part due to the fact that technicians distributed car seats to parents who were using seats deemed unsafe at the first event.* * According to the National Highway Traffic Safety Administration, child

Ev Ev

40%

Correct

20%

19%

100%

87% 93%

40%80% 20%60%

0% 16%

40%

Correct

BeltPositioning Booster

3% There are two ways to install a0%car seat in a vehicle: using the 0% safety belt or using the lower anchors. safety Seat BeltCorrect is Cannot Seatbelt Does Not Know 100% Event 1, n=46 Buckled Touch Move From Rear-Facing ForwardBeltSafety 85% routing means that the safety threaded through the seat correctly and buckled according to Through manufacturer’s instrucEvent 2, n=41 belt is His Toes Side to Side Infant Seat Facing Positioning Belt 80% the Car Seat More Than One Inch 1, n=275 Booster tions. Correct lower anchor useEvent is when bothSeat lower100% anchors are properly hooked into the designated anchors in the vehicle 93% Event 1, n=280 Event 1, n=226 60% 100% 83%Event 1, n=335 Event 2, n=320 43% 87% 93% Event 2, n=269 seat. the back of a vehicle seat, is recommended with both the lower anchors and the safety Event 2, n=253 80% 40% A top tether, which attaches to 80% Event 2, n=335 belt rear-facing seats allow54% for the use of tethers. 100% 100% 20% in a forward-facing seat; not all 60% 60% 86%

00%

20%

ForwardFacing

20% 1%

275 320

93%

80%

40%

60%

Correct Lower Anchor Use

60%

80%

20% 0%

Percent of Seats for which the History Is Known

00%

40%

Booster BeltPositioning Booster

0% Safety 0% Belt Safety Belt

100% <1 80%

0% 2, n=335 Event Correct

% Unable to Determine 40% %

20%

100%

99% 4%

96%

1% 80% 9% 3% 3% 2%to Determine Yes No/Unable 1% 1% 0% 1% knowledge When the Parents’ The60% Child and The caregivers’ Child’s Car Missing about Event 1, n=275 Don’t 0%

THE INTERNAL HARNESS

20%

Event 1, n=292 Event 2, n=315

100%

43% 40%

40%

1% 1% 100% 0% When the

Seat Belt is 80% Correct Buckled

80%

2% 60% 3% 3% Event 1, n=46 85% The Child’s Car The Child Don’t Missing Event 2, n=41 Cannot Seat Does Not Know 40% Data

0% 1% Touch

Move From

Through His Toes Side to Side 20% Harness Recorded as Correct for Were how to correctly 60% the Car Seat More Than One Inch Children Who100% 100% Seat Belt 93% is Cannot Seat Does Not Know Data 43% Event 1, n=280 1% 1% 0% 1% Present at One or Both Events internal harness of a child safety seat 83%improved 0% Event 2, n=320 Buckled use the Touch Move From 40% 40% Event 2, n=269 80% When80% the The Child Th Through His Toes Side to Side greatly from the first event to the second. They were often Seat Belt is Cannot S the Car Seat More Than One Inch 100% 20% EventBuckled 1, n=172 20% 54% 60% 60% Touch unaware of where to position the clip or what slots 4%retainer 80% 1% 78% S EventThrough 2, n=223 His Toes 40% 0% the harness through, the Car40% Seat More 100% to thread and thoseEvent factors most likely 100% 80% 0% 1, n=275 Correct 93% Event 1, n=280 Event 1, n=172 Yes No/Unable to Determine 60% 51% 83% 20%at the first 48% Event 2, n=320 led to the high misuse event. Although 20% 80% numbers Event 2, n=269 78% Event 2, n=223 80% 40% 0% event, more than 15 1% 1% 80% knowledge increased by the second 0 0% Correct 100% When the 51% 48% percent of parents still did not use the internal harness cor- 60% 20%54% Seat Belt is 78% 80% 3% 97% 40% Buckled 0% 60% rectly, which demonstrates that technicians must be even % 3% Event 1, n=254 Through Rear-Facing Forward-Facing 60% more 0% diligent about teaching parents how to properly har5 20% 48% the Car Seat 100%Event 2, n=305 Event 1, n=275 100% 93% Event 1, n=280 BeltSafety children in their seats. 40% ness 83% 40% Event 2, n=320 0%

ositioning Belt Rear-Facing Booster

20%

80%

16% 7%

Beltsitioning Booster

Forward-Facing

19% 6%

Event 1, n=226 Event 2, n=253

13%

Event 2, n=269 20%

80% Correct

54%

60%

40%

100%

60% 3% 86% knowledge vs. practice: 0% seat 81%installation

100%

80%

Fo How can you tell if a child’s seat Rear-Facing 60% 80% 20% 48% Rear-Facing ForwardBeltSafety is installed tightly enough? At40% the first event,Positioning 87 percent of parents assumed they knew how tightly to secure a safety seat in a vehicle, but 40% Infant Seat Facing 60% Belt 0% 46% 42% Seat of both Booster Correct less than half rear-facing and forward-facing seats were actually installed correctly. However, the number Event 1, n=226 40% 20% 19% Event 2, n=253 of 20% tightly installed seats20% rose significantly by the second event, showing that parents increased their ability to cor16% 13% 0% rectly install7% a seat. 6% 100% Rear-Facing 0%

, n=46 , n=41

3% Rear-Facing 0% Forward-Facing 80% Rear-Facing ForwardBeltSafety How can you tell if a child’s seat Infant Seat Facing Positioning Belt 60% is installed tightly Seat Booster enough?

100%

40% Event 1, n=335 20% Event 2, n=335 0%

87% 93%

80% 60%

Percentage of Seats Installed Tightly

100%

20%

40%

, n=280 , n=269

0% 1%

When the Seat Belt is Buckled Through the Car Seat

The Child Cannot Touch His Toes

9% The Child’s Car Seat Does Not Move From Side to Side More Than One Inch

100%

Conclusions 80%

78%

80%

Don’t Know

3% 3% Missing Data

Event 1, n=226 Event 2, n=253

81% Forward-Facing

80% Rear-Facing 60%

1% 1%

46%

42%

40%

86%

81%

42%

86%

46%

20%

Number and Percent of Seats Installed Tightly

Rear-Facing

Forward-Facing

Event 1, n=172 Event 2, n=223

60%

48%education and 51% Traditionally, literacy levels rank as key determinants of health.10 As shown in this study, these Safe Kids 40% Worldwide events tended to follow this trend and reached a highly educated segment of the population. This suggests that 20%passenger safety programs should strategically target families with lower education levels because they are less likely child to attend a safety event. 0% Rear-Facing

Forward-Facing

More than 80 percent of participants self-reported as being white. According to the National Center for Injury Prevention and Control, the percentage of African American children who are injured in traffic incidents is more than twice that of white children.11 Therefore, because the events generally did not reach this group of children who tend to be high risk, this Event 1, n=226 is another target group to take into consideration when developing new programs. Event 2, n=253

Also, children who attended the events tended to be young – ages 4 and under. CSS with internal harnesses are typically appropriate for such children. Older children who should be restrained in booster seats with adult lap-and-shoulder belts are underrepresented in this study. Events should target all children ages 0 to 12, particularly those who are typically underepresented such as the older child. As recorded by CPS technicians at the events, children were more often appropriately restrained at the second event. This shows that hands-on education was successful in teaching parents and caregivers how to safely transport their children. The use of appropriate child restraints increased from the first to the second event, and the number of errors parents and caregivers made in installing safety seats and securing their children in them decreased. At the first event, parents and caregivers made errors in approximately 20 percent of the components used in attaching safety seats to their vehicles and securing their children in them. After having received personalized instruction during the first event, the error rate dropped to an average of 5 percent at the second event. There were also significant increases in the percentage of children with correct 7

harnesses, tight harnesses, correct safety belt routing, tight seat installation and correct lower anchor attachments. The percentage of safety seats with no errors increased by 45 percent. Parents’ and caregivers’ knowledge and skill levels increased after the hands-on education, demonstrating that although teaching proper seat installation through demonstration and discussion is important, it is also vital to have the parent or caregiver take part in the installation process. Research shows that when parents buckle up, they are much more likely to also restrain their children.8 Technicians should therefore take advantage of the opportunity to teach parents and children that all passengers should be properly restrained on every ride. The checkup events also taught parents to only use seats that meet federal safety standards, have not been involved in a crash and have not expired. That knowledge significantly reduced the percentage of inappropriate seats used at the second event. Another positive result was moving children to safer seating positions — out of the front seat, away from active air bags and into a back seat. Based on the results, we are able to conclude that the CSS checkup events conducted by Safe Kids Worldwide coalitions effectively meet their goal of educating and informing parents and caregivers about child passenger safety practices. Parents and caregivers understood and remembered the education, and their attitudes, installation skills and ability to properly secure their children significantly increased from event 1 to event 2. The increase in the number of children riding in appropriate restraints shows that checkup events, and more specifically Safe Kids Worldwide events, are a positive force in preventing childhood injuries from motor vehicle crashes, the number 1 killer of children ages 14 and under. This study was conducted with parents and caregivers who took the initiative to attend the checkup events. They were already concerned about their children’s safety and took measures to ensure that they learned to transport their children properly. The events taught parents the necessary elements of child passenger safety. The next step is to identify and reach parents who do not currently attend such events. This effort will require CPS advocates to become more proactive in reaching underserved families.

Endnotes 1

National Highway Traffic Safety Administration National Center for Statistics & Analysis, Traffic safety facts 2004: Children, (2004).

The National Center for Injury Prevention, WISQARS, http://www. cdc.gov/ncipc/wisqars.

National Highway Traffic Safety Administration National Center for Statistics & Analysis, “Traffic Safety Facts 2005: Children, (2005).

US Census Bureau, 2005 American Community Survey Subject Tables, S2301: Employment Status, http://factfinder.census.gov/ servlet/STSelectServlet (accessed December 15, 2006).

CIA, “The World Factbook,” https://www.cia.gov/cia/publications/ factbook/geos/us.html (accessed December 15, 2006).

US Census Bureau, 2005 American Community Survey Subject Tables, B03001: Hispanic or Latino Origin by Specific Origin, http:// factfinder.census.gov/servlet/STSelectServlet (accessed December 15, 2006).

US Census Bureau, 2005 American Community Survey Subject Tables, S1501: Educational Attainment, http://factfinder.census.gov/ servlet/STSelectServlet (accessed December 15, 2006).

Automotive Coalition for Traffic Safety, “Tween Traffic Safety Research Yields New Safety Tips,” http://www.tweensafety.org/ news_full.php?NewsItem=12 (accessed December 15, 2006).

National Highway Traffic Safety Administration, “Child Restraint Re-use After Minor Crashes,” http://www.nhtsa.dot.gov/people/ injury/childps/ChildRestraints/ReUse/RestraintReUse.htm (accessed December 15, 2006).

10 Ilona S. Kickbusch, “Health Literacy: Addressing the Health and Education Divide,” Health Promotion International 16, no. 3 (September 2001): 289-297. 11 National Center for Injury Prevention and Control, Web-based Injury Statistics Query and Reporting System, http://www.cdc.gov/ncipc/ wisqars (accessed December 15, 2006).

Suggested citation: Jacqueline G. Dukehart, Lorrie Walker, Kathy Lococo, Lawrence E. Decina, and Loren Staplin, “Safe Kids Checkup Events: A National Study” (Washington, DC: Safe Kids Worldwide: 2007). † TransAnalytics, 1722 Sumneytown Pike, Box 328, Kulpsville, PA

Martin R. Eichelberger, M.D., Chair Safe Kids Worldwide 1301 Pennsylvania Avenue, NW Suite 1000 Washington, DC 20004 tel 202-662-0600 fax 202-393-2072