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Jodi A. Lapidus, PhD, Nicole H. Smith, BA, Beth E. Ebel, MD, MSc, MPH and Francine C. Romero, PhD, MPH

Jodi A. Lapidus is with the Department of Public Health and Preventive Medicine, Division of Biostatistics, and the Center for Healthy Communities, Oregon Health & Science University, Portland. Beth E. Ebel is with the Harborview Injury Prevention and Research Center and Department of Pediatrics, University of Washington, Seattle. Nicole H. Smith is with the Northwest Tribal Epidemiology Center, Northwest Portland Area Indian Health Board, Portland, as was Francine C. Romero at the time this research was conducted.

Correspondence: Requests for reprints should be sent to Jodi A. Lapidus, PhD, Department of Public Health and Preventive Medicine, Division of Biostatistics, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail Code: CB-669, Portland, OR 97239 (e-mail: lapidusj{at}ohsu.edu).

	ABSTRACT

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION References

 

Objectives. We sought to estimate motor vehicle passenger restraint use among Northwest American Indian children 8 years old or younger and to determine factors associated with using proper (i.e., age and weight appropriate) passenger restraint systems.

Methods. We surveyed vehicles driven by members of 6 tribes in Idaho, Oregon, and Washington. Associations between proper restraint and child, driver, and vehicle characteristics were analyzed using logistic regression for clustered data.

Results. We observed 775 children traveling in 574 vehicles; 41% were unrestrained. Proper restraint ranged from 63% among infant seat-eligible children to 11% among booster seat-eligible children and was associated with younger child’s age (odds ratio (OR) per year = 0.60; 95% confidence interval (CI) = 0.48, 0.75), seating location (OR front vs rear=0.27; 95% CI=0.16, 0.44), driver seat belt use (OR=2.39; 95% CI=1.51, 3.80), and relationship (OR for nonparent vs parent=0.28; 95% CI=0.14, 0.58). More than half of drivers felt children could use an adult seat belt earlier than recommended guidelines, and 63% did not correctly identify whether their tribe had child safety seat laws.

Conclusions. Children in these communities are inadequately restrained. Restraint use was exceedingly low among booster-eligible children and children riding with unrestrained adults. Interventions emphasizing appropriate restraint use and enforcement of passenger safety laws could reduce the risk of injury or death in motor vehicle accidents.

	INTRODUCTION

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Motor vehicle injuries are the leading cause of mortality among American Indian/Alaska Native (AIAN) children aged 1–4 years.¹ For AIAN children aged 8 years and younger, death rates from motor vehicle crashes are 3 times the national average.^2,3 AIAN children have an elevated risk for injury or death in a motor vehicle crash. In addition, there may be other factors (e.g., cultural, socioeconomic, political, legal) that hinder child safety seat use among American Indians/Alaska Natives. For example, in some rural communities, there may be very few retailers that carry safety seats, making access for American Indians/Alaska Natives difficult.

The use of child safety seats has been proven to reduce child injury and death by 71% for infants and by 54% for toddlers (1–4 years old) in passenger cars.⁴ Booster seats reduce the risk of serious injury by 59%.⁵ Although all 50 states have enacted child safety seat laws,⁶ many children are still inappropriately restrained,^7–9 and when restraint use is known, 53% of fatally injured children are completely unrestrained.⁴ The enforcement of state child passenger safety laws on reservations is variable and depends on tribal agreements.

Few studies have estimated the prevalence of child safety seat use among AIAN children or have ascertained barriers to use. A community child passenger safety assessment conducted among 3 Northwest tribes found that car seat use among children from birth to 4 years of age ranged from 12% to 21%. Car seat use among infants (71%–80%) exceeded use among children aged 1 to 4 years (5%–14%).¹⁰ Restraint use among children age 5 and older was not evaluated, and no detailed information about the proper use of seats was provided.

The goals of this study were (1) to estimate the prevalence of appropriate use of child safety seats among American Indian children 8 years old and younger in 6 Northwest tribal communities, (2) to determine child, driver, and vehicle characteristics associated with appropriate restraint of child passengers, and (3) assess driver knowledge of safety seat guidelines and laws in their communities.

	METHODS

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Study Population
From June through July 2003, we conducted a cross-sectional observational study on the use of infant seats, child safety seats, and booster seats in 6 American Indian tribes in Idaho, Oregon, and Washington. Four of the 6 participating tribes reside on well-defined tribal reservation land, and 2 tribes do not. The 2 Oregon tribes are located in small urban clusters within 60 miles of metropolitan areas of the state. Those in Washington and Idaho are rural reservation communities with predominantly American Indian populations. There is significant economic variation among the 6 tribes; however, all communities have an average per capita income well below the national average, ranging from 47% to 87% of the US average. Between 12.4% and 38.2% American Indian households are below the federal poverty level, compared with 12.4% of households nationally.

Tribal and Institutional Approval Processes
Tribal councils from each participating tribe helped develop study protocols and gave permission to conduct the study on reservation lands. Tribal members advised in the choice of observation sites to maximize the traffic of vehicles. Because sites included local businesses, elementary schools, and childcare centers (5–12 sites per tribe), we obtained permission from proprietors or managers at each site to use their parking lots for data collection. Ninety-six percent of businesses and schools contacted gave permission for us to survey drivers entering or leaving their parking lots. Those sites whose owners refused cited perceived dangerous parking situations and prohibitive policy as the reasons for refusal. Each participating tribe received reports containing their tribe-specific results plus aggregated data from all 6 tribes, which they could use for intervention or policy planning.

Participants
The participants in this research were drivers of vehicles with child passengers 8 years old or under in 6 Northwest tribal communities. Drivers/vehicles were excluded if there were no such children of American Indian descent riding in the vehicle when approached. Data was collected from drivers if there were child passengers for whom the appropriate restraint device was difficult to determine (e.g., a 9-year-old weighing less than 80 pounds); however, these observations were later excluded from analyses. All surveys were conducted in English. All research participants received information about child passenger safety, a free tee-shirt, and a Sacajawea dollar after the survey was completed.

Observation Methods
Trained observers approached all vehicles with child occupants as they entered or exited 47 specified sites on 6 reservations, including local businesses, clinics, elementary schools, and childcare centers. The sites chosen were ones that most tribal members visited on a regular basis. Therefore, observing vehicles at these sites would provide an adequate representation of the community. Observations were conducted during the week (Monday through Friday), usually between 8 AM and 6 PM, which is when children in the age range of interest were most likely to be traveling. No identifying information was collected from occupants or vehicles. If the vehicle was entering the parking lot, it was approached before the driver had unfastened his or her seat belt. If the vehicle was leaving the parking lot, it was approached after the driver had the opportunity to secure children and to fasten his or her own seat belt.

Once a driver gave verbal consent to participate in the anonymous interview, the goals of the study were explained, and drivers were given a study information sheet. They were asked to confirm their American Indian heritage and whether there were passenger(s) in the vehicle who were 8 years old or younger. Drivers were asked the age and weight of each child, vehicle model year, and the distance they were from home (in minutes). Trained observers looked into the car to assess seating location and restraint use by the driver and all child occupants. Drivers were queried about their reasons for restraint choice and responses were recorded verbatim. Drivers were also asked at what age and weight they felt a child was old or large enough to use an adult seatbelt. Drivers’ awareness of local child safety seat laws and interest in attending training on child safety seats were also recorded. All responses from the observation and driver survey were recorded on a 1-page data collection instrument adapted for this study from previously implemented studies.^7,11 For drivers who refused to complete the survey, observers recorded the reason for refusal, gender, and whether the driver was wearing a seat belt.

All observers were systematically trained in proper restraint use for infants and children at Harborview Injury Prevention & Research Center. The principal investigator monitored the quality of the observation process by periodically reviewing observers’ technique in the field and providing feedback.

Data Analysis
We defined a child who should use a rear-facing infant seat as any child < 1 year old (infant seat-eligible). A child between 1 and 4 years of age and weighing less than 40 pounds was defined as child seat-eligible. A child between 40 and 80 pounds and between 4 and 8 years old was considered booster seat-eligible. Three-year-old children weighing 40 pounds or more were also characterized as being booster seat-eligible, because the majority of child harness seats have a top weight limit of 40 pounds. Children who weighed more than 80 pounds or who were older than 8 years were considered big enough for the adult lap and shoulder belt and were excluded from this analysis.

We present descriptive statistics for children, drivers, and vehicles in the form of mean ±SD for continuous variables, and percentages for categorical variables. Characteristics associated with proper restraint use were assessed using univariate and multivariate logistic regression. We used the generalized estimating equations (GEE) method^12,13 to account for the clustered nature of the data, in that restraint use by each child in a vehicle and vehicles observed at the same site cannot be presumed to be completely independent of one another.

We examined the association between each potential risk factor and proper restraint individually by computing crude odds ratios and 95% confidence intervals. Factors that were statistically significant at the.05 level were entered into the multivariate logistic regression model, and interactions between risk factors were evaluated. Age effects were assessed both continuously (per year) and categorically (< 1, 1–3, > 4). In addition, tribe was entered into the multivariate model to adjust for observed and unobserved differences between communities/locations involved in the study.

Open-ended responses to the driver knowledge and opinion portion of the survey were categorized into conceptual groups by project analysts and reviewed by the principal investigator. Percentages of drivers responding to each group were tabulated. We coded drivers’ knowledge about existence of safety seat laws as correct or incorrect depending on the laws for each specific tribe.

Descriptive analyses were conducted using SPSS version 11.5 (SPSS Inc., Chicago, IL), and inferential analyses were conducted using SAS version 8 (SAS Institute, Cary, NC).

	RESULTS

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We obtained consent from 594 drivers, and recorded information on 806 children traveling with them. This represents 88% of all drivers approached during the study period. Driver refusal rates differed somewhat by tribe, ranging from 5% to 19%.

A total of 775 children (in 574 vehicles) met criteria for infant seat, child seat, or booster seat use. Characteristics of these children, the drivers, and vehicles are presented in Table 1. Mean child age was 3.8 years (SD= 2.2 years); mean weight was 40 pounds (SD= 16 pounds). Children were most commonly seated in the rear outboard (53%) or rear center seats (15%); however, 32% of children were front-seat passengers. Almost three fourths (73%) of drivers were female, and, on average, were 12 minutes from home. Sixty-eight percent of the child passengers were driven by a parent, and 32% were driven by another relative or friend.

Restraint Use and Misuse
As shown in Figure 1, 63% of infant seat-eligible children were properly restrained in rear-facing infant seats, 41% of child seat-eligible children were in child harness seats, and only 11% of booster seat-eligible children were in booster seats. Among all children observed, 41% were completely unrestrained in the car. Of infant seat-eligible children, 21% were completely unrestrained. Of child seat-eligible children, 37% were completely unrestrained. Booster seat-eligible children were at particular risk of riding unrestrained (49%).

View larger version (11K): [in this window] [in a new window]   FIGURE 1—— Percentage of American Indian children properly restrained in motor vehicles, by recommended restraint in 6 northwest tribes.

Associations with Proper Child Restraint
Results from the GEE logistic regression models evaluating associations with proper child restraint are presented in Table 3. In our tribe-adjusted models, child characteristics significantly associated with proper restraint use included age, weight, seating location, and relationship to driver. Driver characteristics that were significantly associated included driver’s seat belt use and driver age (columns 2 and 3 of Table 3). Proper child restraint was not significantly associated with the length of the trip, vehicle model year, or the gender of the child or driver.

Driver Survey Results
Approximately half of the drivers reported that they felt children were old enough to use an adult seatbelt at or before 6 years (49%) and/or 60 pounds (57%), even though safety experts recommend booster seat use until 8 years and 80 pounds.^14,15 However, neither of these beliefs was associated with child restraint use.

Nearly half of all drivers (47%) responded that they did not know whether there were child restraint laws in their community. Only 38% of drivers reported correctly whether their tribe was subject to child restraint laws, and the percentage differed significantly depending on whether the laws were tribal, state, or nonexistent (₂² = 24.7, P < .0001).

Forty-six percent of drivers in the 3 tribes who had enacted tribal laws and enforced them via tribal police reported correctly, whereas only 24% were correct in 2 tribes subject to state law (enforced by state police). In the one tribe with no law at all, 39% reported correctly. Those who incorrectly reported law status were slightly, but not significantly, less likely to have properly restrained children in the vehicle (OR = 0.83; 95% CI = 0.58, 1.20). The law status itself (tribal, state, or none) was not a significant predictor of proper restraint. Fifty-nine percent of drivers reported that they would be interested in receiving more information or training on child safety seat use, but this was not a significant predictor of proper restraint use.

Drivers of the 71 booster seat-eligible children who were observed in their booster seats cited reasons for use such as "safety" (25%), "best fit for child" or "allows child to see out" (24%), "it is the law" (11%) and "got it for free" (11%). Forty-four percent of drivers who had unrestrained or improperly restrained booster seat-eligible children in the vehicle (n = 247) reported that they did indeed own a booster seat. However, most often cited reasons for not using booster seats among this group were "do not have" or "lost/broken" (19%), "child too big or too old" (14%), and "seat in another vehicle" (13%). Other reasons given included "could not afford" (6%), "child does not like" (5%), "no room for seat in vehicle" (6%), "short trip" (5%), and "don’t usually transport child" (4%).

	DISCUSSION

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION References

 
In these 6 northwest tribal communities, American Indian children traveling in motor vehicles are inadequately restrained, putting them at increased risk for injury and/or death from motor vehicle crashes. Four of every 10 children were completely unrestrained in the car, putting these children at even greater risk.^2,4 The percentage of children riding unrestrained was substantially higher than the 12% reported by the National Highway Transportation and Safety Administration (NHTSA) on the basis of data from the same 6 states.¹⁶

Proper restraint use was highest for children younger than 1 year (63%), followed by child seat-eligible children (41%). These percentages are lower than those reported by Ebel et al.⁷ for children in Seattle, Spokane, and Portland (80% for child seat-eligible). However, in both this study and that of Ebel et al.,⁷ the proportions of booster seat-eligible children (children aged 4–8 weighing 40–80 pounds) who were properly restrained are alarmingly low (11% and 17%, respectively). This is not a regional phenomenon. The February 2004 report from the NTHSA 6-state study stated that child restraint use was 97%, 86%, 42%, and 11% for children under 20 pounds, 20 to 39 pounds, 40 to 59 pounds, and 60 to 79 pounds, respectively.¹⁶

Several factors associated with proper child restraint in this study (driver belt use, child age) were identified previously in non–American Indian populations.⁷ Our study illuminates that in American Indian communities, non-parent drivers are significantly less likely to properly restrain children and often did not have the appropriate child restraint device in the vehicle. In addition, we also found that older parents were more likely to have properly restrained their child passengers, but this age association was not found for nonparental drivers. This suggests that nonparent care-givers of all ages, as well as younger parents, may benefit from an intervention aimed at increasing child restraint use in vehicles.

Not only was driver seatbelt use a factor associated with proper child restraint in this study, but we also found that the drivers of the American Indian children in this study were less likely to wear their own seatbelt compared with general population in the area. Half of drivers (51%) surveyed were wearing a seatbelt, ranging from 22% to 79% by tribe. In comparison, seatbelt use is much higher among the general population in Idaho (63%), Oregon (88%), and Washington (95%).⁹ Interventions aimed at increasing restraint use among American Indian children could include an emphasis on the driver’s safety, and an intergenerational focus might prove effective in tribal communities.

It has been documented that enactment and enforcement of child restraint laws is an effective injury prevention effort for American Indian children¹⁷ as well as in the community at large.¹⁸ Although we did not assess the level of enforcement of child passenger laws in the 6 tribal communities, we did assess drivers’ awareness of the existence of tribal child safety seat laws in their communities. Nearly half (47%) said they "did not know" whether their tribe had child safety seat laws. Knowing whether the tribe was subject to some child restraint law was not significantly associated with proper restraint of children observed in this study; the type of law (tribal, state, or none) was not significantly associated with proper restraint of children.

Because proper use of booster seats is so low in this and other communities, it was important to evaluate reasons that drivers gave for not using them. Many of the responses given in this study were similar to those reported by Ramsey et al.,¹⁹ such as the driver’s belief that the child was large enough to not need a booster seat. Fifty-seven percent of drivers studied in King County, Wash,¹⁹ claimed that they did own a booster seat but were not using it when observed. In the current study, this figure was slightly lower (44%), and more respondents reported that they did not have, lost, or could not afford a booster seat. Reasons for nonuse reported here fell into conceptual domains similar to those outlined in the qualitative study by Simpson et al.²⁰: lack of knowledge, gaps in child passenger and safety seat laws, situational influences (e.g., short trips), attitudes about booster seats, child behavior, inconvenience, and cost.

Drivers in the tribal communities in this study do report that they would be interested in receiving additional training on child safety seat use, and educational interventions seem to be warranted. Community campaigns have proven successful at increasing booster seat use.^11,21 Similar interventions in one or more of these communities, designed and implemented in a participatory process and aimed at community priorities and concerns, could prove successful at increasing proper restraint use for infant seat, child seat and booster seat-eligible children. Finally, interventions will probably need to address resource availability limitations in tribal communities to ensure that parents and other drivers of children have access to appropriate child restraints.

Limitations
Our study has some limitations. We did not gather information on all passengers in the vehicle, only the driver and all children aged 8 years old and younger. Thus, we did not record the total number of people in the vehicle or whether the number of persons in the vehicle exceeded the number of available seating positions. In addition, we relied on reported age and weight of the children and did not independently validate driver report. We also did not ask drivers to estimate child height. Child height is part of some of the published criteria for assessing recommended restraint.^14,15 However, prior investigators have noted that most drivers were not able to report child height.⁷ Therefore, we did not ask drivers to estimate child height and determined recommended restraint use on the basis of child age and weight. We confined the study to American Indian children and drivers. If a non–American Indian driver volunteered that there were American Indian children riding in the vehicle, we included them in the study. However, we could have missed American Indian children traveling with non–American Indian drivers if the driver did not volunteer the race of the children. Finally, trained observers did not enter the vehicle to assess whether safety seats were correctly installed. Thus, proper restraint may be overestimated.

Conclusions
Motor vehicle crashes remain the leading cause of death for all American Indian children. There is overwhelming evidence that child safety seats are effective at reducing injury when used properly.^4,5,16 Despite national progress in increasing seat belt and child restraint use, our study shows that American Indian children in tribal communities in the northwestern US face epidemic rates of being completely unrestrained (41%) or improperly restrained (30%). Children between 4 and 8 years of age are at particular risk for improper use of booster seats. Factors associated with proper restraint use include child age, weight, seating location, relationship to driver, and driver’s use of seat belt. Although adult drivers in these communities were commonly unaware of laws regarding vehicle restraints for children, they were receptive to receiving more information and training on proper use of child safety seats. Culturally appropriate interventions to increase use of infant, child, and booster seats should be designed and implemented with tribal communities as full partners in the process. Such interventions might include strategies to get all occupants (adults and children) to use proper restraints; stress importance of regular use, even for short trips; increase availability of proper seats for all vehicles that children ride in regularly; and include training on proper use, not only for parents but also for all regular caregivers. Community-based initiatives aimed at improving enforcement of existing child passenger safety laws and/or extending laws to cover safe transportation of children through age 8 could also be effective.

	Acknowledgments

 
This study was funded by the Native American Research Centers for Health (grant 1U269400013-01).

We thank the members of the 6 Northwest tribes who participated in this study, including the tribal council members, tribal health personnel, and business owners who recognized the need and ultimately approved this research project for their communities. We would also like to express our appreciation to the field staff from each community and the Northwest Portland Area Indian Health Board for their diligent work in recruiting participants and collecting high-quality data. In addition, we thank Lisa deRoo, Dee Robertson, Paul Stehr-Green, and Thomas Becker for providing input and expertise into the project’s conception as well as for obtaining funding. Finally, we express the utmost appreciation to the survey participants, who shared their time and information to improve the health and safety of American Indian children.

Human Participant Protection
Oregon Health and Science University and Portland Area Indian Health Service institutional review boards reviewed and approved this project. Each participating tribe gave approval to conduct this project on tribal lands.

	Footnotes

 
Peer Reviewed

Contributors
J. A. Lapidus led the preparation of the article and designed and conducted the statistical analyses and the reports presented to participating tribes. N. H. Smith collected and entered data and provided substantial assistance in statistical analyses and reports presented to tribes. B. E. Ebel consulted on the design of the study, the development of data collection instruments, and the training of field personnel and made substantial contribution to the writing of the article. F.C. Romero obtained institutional review board and tribal approvals, trained interviewers, set up field sites, collected data, set up databases, entered data, and oversaw data analyses. She also made substantial contribution to the writing of the article and presented the results to participating tribes and Northwest Portland Area Indian Health Board tribal delegation.

Accepted for publication March 25, 2005.

	References

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1. Indian Health Service. Regional Differences in Indian Health. Rockville, MD: US Department of Health and Human Services, Indian Health Service, Office of Public Health, Division of Program Statistics.

2. Centers for Disease Control and Prevention. Injury mortality among American Indian and Alaska Native children and youth—United States, 1989–1998. MMWR Morb Mortal Wkly Rep.2003;52:697–701.[Medline]

3. Centers for Disease Control and Prevention. Web-based injury statistics query and reporting system (WISQARS), Injury Mortality Reports, 2000–2001. National Center for Injury Prevention and Control. Available at: http://webappa.cdc.gov/sasweb/ncipc/mortrate10_sy.html. Accessed January 10, 2005.

4. US Department of Transportation. Traffic Safety Facts 2002. Washington, DC: National Highway Traffic Safety Administration & National Center for Statistics and Analysis, US Department of Transportation; 2004. DOT HS 809 620.

5. Durbin DR, Elliott MR, Winston FK. Belt-positioning booster seats and reduction in risk of injury among children in vehicle crashes. JAMA.2003;289: 2835–2840.[Abstract/Free Full Text]

6. Insurance Institute for Highway Safety. Child restraint laws. Available at: http://www.hwysafety.org/safety%5Ffacts/state%5Flaws/restrain4.htm. Accessed January 10, 2005.

7. 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–e327.[Abstract/Free Full Text]

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11. Ebel BE, Koepsell TD, Bennett EE, Rivara FP. Use of child booster seats in motor vehicles following a community campaign. JAMA.2003;289:879–884.[Abstract/Free Full Text]

12. Liang KY, and Zeger SL. Longitudinal data analysis using generalized linear models. Biometrika.1986; 73:13–22.[Abstract/Free Full Text]

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14. National Highway Transportation Safety Administration. Proper child safety seat use chart. Available at: http://www.nhtsa.dot.gov/portal/site/nhtsa/menuitem.9f8c7d6359e0e9bbbf30811060008a0c. Accessed January 10, 2005.

15. American Academy of Pediatrics. Car safety seats: a guide for families, 2002. Available at: http://www.aap.org/family/carseatguide.htm. Accessed January 10, 2005.

16. US Dept of Transportation. Misuse of child restraints. Washington DC: National Highway Traffic Safety Administration. Available at: http://www.nhtsa.dot.gov/people/injury/research/Misuse/images/misusescreen.pdf. Accessed January 10, 2005.

17. Phelan KJ, Khoury J, Grossman DC, et al. Pediatric motor vehicle related injuries in the Navajo Nation: the impact of the 1988 child occupant restraint laws. Inj Prev.2002;8:216–220.[Abstract/Free Full Text]

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20. Simpson EM, Moll EK, Kassam-Adams N, Miller GW, Winston FK. Barriers to booster seat use and strategies to increase their use. Pediatrics.2002;110(4): 729–736.[Abstract/Free Full Text]

21. Washington State Booster Seat Coalition. Building a booster seat campaign: a guide for community organizers, health educators and injury prevention specialists. Seattle, WA: Harborview Injury Prevention & Research Center; 2004.

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This Article Abstract Figures Only Full Text (PDF) All Versions of this Article: AJPH.2004.052514v1 95/11/1982    most recent Submit a response View Shopping Cart Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Similar articles in this journal Similar articles in ISI Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via ISI Web of Science (2) Citing Articles via Google Scholar Google Scholar Articles by Lapidus, J. A. Articles by Romero, F. C. Search for Related Content PubMed PubMed Citation Articles by Lapidus, J. A. Articles by Romero, F. C. Related Collections Injury/Emergency Care/Violence Prevention Other Child and Adolescent Health Native Americans Surveys