4.0 SUMMARY AND RECOMMENDATIONS This chapter summarizes findings from the data analyses; and provides recommendations for future research. 4.1 SUMMARY The study began with a workshop with child passenger safety experts from the fields of biomechanics, injury prevention, public health, occupant protection systems, and highway safety education to discuss and prioritize the most critical CRS misuse characteristics associated with serious injury. A list of critical misuses was developed and used to formulate data collection procedures and instruments. CRS use and misuse observations were conducted across a wide range of geographic regions in the country by teams of AAA-certified child passenger safety (CPS) instructors and technicians. These teams attended a train-the-trainer workshop hosted by the contractor in Philadelphia, PA to finalize data collection instruments and critical CRS misuse definitions, as well as to discuss data collection procedures. Prior to collecting data, the teams recruited greeters and additional certified CPS technicians. These local teams were given two-day training programs and observed closely in the field for the approximate two-month data collection period. The regional data collection sites were Tucson (Arizona), Boca Raton/Fort Myers/Fort Pierce/Miami (Florida), Jackson (Mississippi), St. Louis (Missouri), Carlisle/Harrisburg (Pennsylvania), and Bellevue/Seattle/Tacoma (Washington). Site locations were predominantly parking areas of community shopping centers. However, many sites consisted of parking areas at fast-food restaurants, health and medical centers, and stores specializing in infant and children"s merchandise. Community events were also used to collect data. A convenience sampling approach was used. Sites needed to have a high volume of young children. Permission from shopping center owners or managers was required for a site to be considered acceptable for study. Additional site selection criteria were size of parking lot, number of exits and entrances, and traffic patterns. Malls and large shopping centers were avoided. Local and community shopping centers were primary choices for sites. Demographics of the communities were also considered. A wide range of ethnic and socio-economic variables was used in identifying appropriate sites. The data collection procedure involved intercepting potential target vehicles (driver with young children less than 80 lb), explaining the purpose of the stop, asking permission to make observations, and directing the driver to a safe parking area. If permission was received from the driver, the observer entered the vehicle and made observations of restraint use and misuse by the children, and recorded the information. At the same time, the greeter recorded information about age and weight of the children, seating position of the children, and type of restraints used by the driver and children. Once all the information was collected, the data collection team thanked the driver and then moved back into position to find the next vehicle meeting the sampling criteria. Observation data were collected on 5,527 children less than the weight of 80 lb. Overall restraint use was 88.2%, as 62.3% used a CRS and 25.9% used a safety belt (SB). A comparison of data for all children less than 60 lb with the previous NHTSA CRS misuse study by Decina and Knoebel (1996) showed that overall restraint use improved by only 3.3%. However, CRS use increased by 20.9%, while SB use decreased by 17.6%. Thus more children in the less than 60 lb category are remaining in CRSs than was evident in the earlier study of over 7 years ago. The study found overall critical CRS misuse continues to be a problem in the country. CRS misuse— based on the critical CRS misuse measures identified by experts as having significant injury potential—was 72.6%. The most common critical misuses were loose harness straps securing the child to the CRS and loose vehicle SB attachment to the CRS. Critical misuse remains fairly high for CRSs used by infants and young children less than 40 lb. Infant seats showed the highest misuse (83.9%) followed by rear-facing convertible seats (83.5%), forward-facing convertible seats (81.9%), and forward-facing only seats (79.3%). The most common types of critical misuses for these CRSs were loose harness straps and loose vehicle safety belts. Critical misuse was much lower for CRSs used by young children from 40 to 79 lb. Beltpositioning booster seat misuse was 39.5%. Shield booster seats showed misuse of 60.5%. The most common form of critical misuse for these CRSs was that the child did not fit appropriately in the seat. Premature movement of the child from CRS to SB remains a serious problem. While children less than 20 lb and 20 to 39 lb are predominantly in CRSs (97.1% and 86.4%, respectively); only 41.7% of children 40 to 59 lb were in a CRS, compared to 43.1% in SBs. Even worse, only 10.9% of children 60 to 79 lb were in a CRS, compared to 64.9% who were in a SB. The study found that 11.8% of children less than 80 lb were not using any type of restraint system. For children less than 60 lb, 9.6% were unrestrained. The previous NHTSA CRS observation study (Decina and Knoebel, 1996) reported 12.8% of children less than 60 lb unrestrained. Driver SB use continues to be related to restraint use by children. When drivers were belted, 91.7% of children less than 80 lb were restrained in either a CRS or SB. When drivers were unbelted, only 62.3% of children less than 80 lb were restrained. For belted and unbelted drivers, 44.2% and 43.2% of children less than 80 lb were in a CRS, respectively. Comparison with the NHTSA National Occupant Protection Use Survey (NOPUS), which provides the only National probability based observation data on the use of child restraints (CRS or SB) on the Nation"s roads, revealed results similar to this study, in terms of overall restraint use (CRS or SB) for infants, children ages 1 through 3, and children ages 4 through 7. In addition, the relationship in NOPUS of driver restraint use to child restraint use was very similar to the findings of this study. Both NOPUS and this study found that when the driver was belted, over 90% of observed children were restrained (CRS or SB). A large proportion of the vehicles that were stopped in this study had driver frontal air bags (83.1%) and passenger frontal air bags (71.8%). Only 4.6% of the vehicles had front side air bags; and only 1.3% had front side and rear side air bags. Only a small percentage of the vehicles (less than 5%) had on/off air bag switches. Of the 88 switches checked for the on/off position, 16 children were in the front seat with an air bag switch in the "on" position. Of the 16 children, 2 were in rear-facing CRSs, 4 were in forward-facing seats, 3 were in SBs, and 7 were unrestrained. 4.2 RECOMMENDATIONS Recommendations are given for future research and enforcement and education programs. Research - Periodic Monitoring of CRS Misuse Periodic monitoring of CRS misuse among the general public is recommended. Biennial or triennial monitoring would be reasonable. There are several reasons for this recommendation. Vehicle manufacturers are constantly upgrading and changing designs of their occupant protection systems. While all new vehicles include driver and passenger frontal air bags, many also include newer side air bags. In addition, as of Fall 2002, all vehicles are required to have the LATCH system in place (Stewart and Kern, 2003). These changes can directly affect the ability of the public to provide the safest occupant protection for young children. As more people acquire newer vehicle models, the issues (and misuses) associated with CRS compatibility with air bag position and CRS use with LATCH will need to be identified and addressed. While proper use of a LATCH system is designed to eliminate the need for a vehicle SB and any associated misuses in CRS installation in the vehicle, CPS technicians are finding LATCH system misuses at inspection stations. Parents/caregivers are sometimes not using the top tether, not hooking the lower attachment to the lower anchor, or hooking the lower attachment incorrectly (upside down) (Osterhuber, 2003). Another reason for periodic monitoring of CRS misuse involves the current status of occupant protection laws in the fifty States. Many States have either recently passed booster seat laws or have bills under consideration. These laws vary from State to State in terms of age and weight restrictions. As these laws take effect, it will be important to monitor public compliance and CRS misuse. CRS misuse observations with the general public should be made by qualified and experienced personnel who are trained to gather CRS misuse data. Despite the public"s general willingness to participate in these studies, drivers are willing to volunteer only a limited amount of time to an observation survey. Thus, there is a need to be efficient, accurate, and quick in methods used to observe and record restraint system use and misuse. State and regional highway safety organizations offer NHTSA standardized child passenger safety training courses. It is recommended that field observers be course-certified technicians or instructors. In order to gain field observer experience, it is also recommended that individuals participate in local community CRS safety checks. For researchers involved in CRS misuse observation studies, NHTSA provides (on their Web site - www.nhtsa.dot.gov) a list of certified instructors and technicians in each State. This list can be quite helpful as a starting point in recruitment. Field observation studies of this nature should employ train-the-trainer workshops for supervisors, field managers and senior field observers; and training sessions for greeters and field observers at the local site level. The train-the-trainer workshops should focus on identifying the critical CRS misuse measures and how to observe, identify and record these measures. Data collection forms should include categories in line with defined CRS misuse measures. Forms should be structured to allow for expeditious recording of information. Check off boxes or codes to circle are recommended. Single-sided forms are also suggested. At least two days of time should be spent training field observers. Classroom time should be spent covering the following: Review of CRS types and misuse measures. Procedures for recruiting the public. Techniques to interact with drivers. Methods to make CRS misuse observations and record data. Role-playing should be conducted in a parking lot before going out into a real field observation environment. Field staff should be observed in action for at least two full days. Other Research Needs Engineering approaches have been developed (e.g., LATCH) to reduce the problems of a loose CRS to the vehicle. Loose harnesses are more of a challenge. This misuse can stem from drivers not properly following harness strap procedures (e.g., position of straps in slots, threading of harness through slots, retainer clip placement, buckling of crotchplate, and tightness of straps on child). Research needs to identify the most effective educational approaches that will help drivers understand and focus on this critical CRS misuse issue. Efforts to reduce critical CRS misuses should extend beyond relying on parents/caregivers to read and correctly follow manufacturer instructions. Findings from a NHTSA telephone survey found 74% of parents/caregivers learned how to install the CRS that their child used by reading the instructions (Block, 2002). With such a high rate of critical CRS misuse evident, reading instructions is clearly not enough. Maybe, more hands-on approaches are necessary. Research should focus on the effectiveness of hands-on demonstrations available at CRS inspection clinics or events, and the programs and media necessary to get parents/caregivers to go to these places. The NHTSA telephone survey found that only 13% of parents/caregivers of children who used a CRS reported visiting an inspection station (Block, 2002). This study found a large percentage of children (nearly 12 percent) unrestrained. Are the media not reaching this group? Are loaner programs ineffective? Are socioeconomic and demographic factors the reason? What do we need to do to increase CRS use, not just CRS correct use, by the public? Enforcement Enforcement of traffic safety laws has been effective in influencing the behavior of the public in a number of traffic safety areas, including restraint use. NHTSA surveys show the public generally agreeing that it is important to enforce the child passenger safety (CPS) laws (Block, 2002). The current study found that non-use of any restraint occurred with some frequency among the child population, particularly among children 60 to 79 lb. Enforcement of CPS laws in such situations is rather straightforward, and needed. But this study also found instances where parents were using the wrong restraint for the child. For example, many children less than 9 years of age were in vehicle safety belts instead of child restraint systems. A number of these children were in clear violation of the CPS laws in their States. The only way that enforcement of correct restraint use will occur is to have effective programs that make law enforcement agencies aware of the importance of correct CRS use, as well as keeping children in CRSs as long as possible. Recognizing the benefits of booster seat use for children ages 4 through 8 may lead to the development of enforcement strategies on how to identify this problem on the highways and cite violators of booster seat laws. Law enforcement agencies across the country should actively take a role in communitybased CRS education programs. Many law enforcement officers are CPS-certified and provide CRS installation checks at their stations. They regularly participate at "car seat safety check" events; and they conduct "education checkpoints" to facilitate CRS use and misuse surveys. Their involvement with these programs and other CPS education activities encourages public compliance with the occupant restraint laws, promotes driver and passenger restraint use, likely improves proper CRS use, and presents a positive public image of law enforcement and strengthens community relationships. Education As evident from the results of this study (i.e., high levels of CRS misuse, inappropriateness of restraint types, and unrestrained young children), education programs should continue to promote proper use of CRSs, occupant restraint laws, enforcement of these laws, availability of CRS inspection stations, loaner programs, and local and National CRS hotline information assistance. Programs should also provide information about new technology relating to vehicle occupant protection systems (e.g., side air bags) and CRSs (e.g., LATCH system).