An Emergency Department Intervention to Increase Booster Seat Use for Lower Socioeconomic Families Michael A. Gittelman, MD, Wendy J. Pomerantz, MD, MS, Susan Laurence
Abstract Objectives: To evaluate the effectiveness of booster seat education within an emergency department (ED) setting for families residing in lower socioeconomic neighborhoods. Methods: This was a prospective, randomized study of families with children aged 4 to 7 years and weighing 40 to 80 lb who presented to a pediatric ED without a booster seat and resided in lower socioeconomic communities. Subjects were randomly assigned to one of three groups: 1) received standard discharge instructions, 2) received five-minute booster seat training, and 3) received five-minute booster seat training and free booster seat with installation. Automobile restraint practices were obtained initially and by telephone at one month. Results: A total of 225 children were enrolled. Before randomization in the study, 79.6% of parents reported that their child was usually positioned in the car with a lap/shoulder belt and 13.3% with a lap belt alone. Some parents (16.4%) had never heard of a booster seat, and 44.9% believed a lap belt was sufficient restraint. A total of 147 parents (65.3%) were contacted for follow-up at one month. Only one parent (1.3%) in the control group and four parents (5.3%) in the education group purchased and used a booster seat after their ED visit, while 55 parents (98.2%) in the education and installation group reported using the booster seat; 42 (75.0%) of these parents reported using the seat 100% of the time. Conclusions: Education in a pediatric ED did not convince parents to purchase and use booster seats; however, the combination of education with installation significantly increased booster seat use in this population. ACADEMIC EMERGENCY MEDICINE 2006; 13:396–400 ª 2006 by the Society for Academic Emergency Medicine Keywords: emergency department, education, booster seat
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elt-positioning booster seats are currently recommended for children from about age 4 years and 40 lb to at least age 8 years unless greater than 4 feet, 9 inches tall.1 This transitional seat is designed for a child who has outgrown a convertible child safety
From the Divisions of Emergency Medicine (MAG, WJP) and Trauma Services (SL), Cincinnati Children’s Hospital Medical Center, Cincinnati, OH. Received September 29, 2005; revisions received October 3, 2005, and October 31, 2005; accepted November 2, 2005. Presented in abstract form at the American Academy of Pediatrics annual meeting, New Orleans, LA, November 2003. Supported by AllState Foundation (research funds and car seat technician support) and Ford Motor Co. (‘‘Boost Up America Campaign’’ for 225 low back booster seats). Address for correspondence and reprints: Michael A. Gittelman, MD, Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, ML# 2008, Cincinnati, OH 45229. Fax: 513-636-7967; e-mail:
[email protected].
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seat but is too small to use a vehicle’s safety belt. The purpose of the booster seat is to elevate a child in the automobile’s chair so that the lap belt fits across the child’s pelvis, not abdomen, and the shoulder belt does not override on the child’s neck. Serious injuries have been documented when children in this age range are not restrained properly.2,3 In fact, Durbin et al. have shown that the odds of injury are 59% lower if an appropriately aged child is restrained in a belt-positioning booster seat compared with a vehicle safety belt.4 In their study, no child experienced any abdominal, neck, back, or lower extremity injuries if he or she was properly restrained in a belt-positioning booster seat. Despite the obvious benefit of these seats, children and their families are not commonly using them; only 10%– 28% of children observed or recorded at crash sites have been properly restrained in a booster seat.5–7 Unpublished data obtained in 2000 at Cincinnati Children’s Hospital Medical Center (CCHMC) showed that only 8% of children were observed to be in belt-positioning booster seats after 2,300 car seat checks. Rivara et al.
ª 2006 by the Society for Academic Emergency Medicine doi: 10.1197/j.aem.2005.11.002
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reported that parents were ‘‘confused about the appropriate weight and age of children who should be placed in a booster seat.’’8 Ramsey et al. provided another explanation for dismal seat use as they showed that parents believed children fit appropriately in a lap/shoulder belt.7 Educating families and then providing them with free booster seats9 or rebates to obtain a booster seat at a later date10,11 have been shown to increase their seat use; however, the overall use of booster seats at the end of these studies was still 50% increase in their use of the safety devices when compared with parents in the control group. Other researchers have attempted to provide injury prevention education to families in the ED setting who are not being seen for an injury complaint. Quan et al. provided families with drowning prevention information with their ED discharge instructions.15 Families appreciated the information and wished to learn more about drowning prevention after their ED visit. Zonfrillo et al. showed that ED discharge instructions with motor vehicle child restraint information educated parents about appropriate restraints and that a subgroup changed their behavior after receiving the literature.16 In the present study, patients who presented to a pediatric ED for any chief complaint were enrolled and offered educational information about belt-positioning booster seats and were able to ask questions after the presentation. Interestingly, parents in the belt-positioning booster seat education group did not significantly change their safety restraint practices compared with controls. One reason our study may not have shown education alone to be successful in the pediatric ED setting was that the outcome measure was purchasing and using a booster seat. In the other studies mentioned, the outcome was using a seat belt or altering a home to be safer, both of which did not require a family to spend large amounts of money. Families in our study reported that the cost of the seat, lack of need for a seat, and not always having an automobile were important reasons for not purchasing the restraint device after the intervention. Furthermore, when given a free fitted booster seat along with the education, almost every family reported appropriately restraining their child in a booster seat. Interestingly, the increase in booster seat use within our study located in the ED setting was far greater than the increase in the study by Apsler et al. in a Head Start setting, where a similar intervention of education and providing free booster seats to participants occurred.11 This finding may indicate that the ED setting is a more appropriate place to discuss this type of anticipatory guidance counseling and provide at-risk families with booster seats. It must be acknowledged that the outcome in the study by Apsler et al. was observed seat use and in our study was self-reported seat use. However, the
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change in booster seat use that we observed after the intervention in the ED setting was far greater than in the study by Apsler et al., and self-reported prevention practices have been shown to be fairly reliable compared with observational practices.21,22 LIMITATIONS There are some limitations to consider in the interpretation of our results. First, the information on booster seat use at the one-month follow-up was self-reported. Acquiescence bias may have influenced families who received a free booster seat to overemphasize the use of the seat they received. If this bias occurred, one might expect that families who received prolonged education in the ED would acquiesce as well and admit to an increase in booster seat use; however, this group was no different from controls. It may have been more helpful to observe these patients at follow-up; however, the same bias that occurred in self-reported follow-up may have occurred during seat observations. Follow-up at one month may have also been too short a period to make any determination about future behavior. Although the majority of families in the booster seat giveaway and education group tended to always use the safety seat given, this behavior may dissipate over time. Future prolonged observations would be necessary to determine if the behavioral change from the intervention is sustained or self-limited. Another limitation was that the study population was a convenience sample. It would have been helpful to determine if patients who presented due to a motor vehicle crash or other injury complaints reported safer automobile restraint practices at follow-up compared with children seeking care for other reasons. Our sample size did not allow for this type of analysis, and future examinations as to which type of patients benefited most from anticipatory guidance counseling in the ED setting should be undertaken. The dropout rate was underestimated in our calculation of the sample size. This miscalculation could have lowered the power of our findings; however, the difference in the results was so dramatic that the number of patients enrolled clearly showed a significant difference between patients receiving a booster seat and education and the other two groups studied. Finally, this study was performed in a pediatric academic ED. Other ED settings may not be able to justify similar time and staffing needs to be able to reproduce this study. However, the research assistant employed for this project was a layperson and required only one week of car safety seat training before enrolling patients. CONCLUSIONS In summary, with motor vehicle collisions as the leading cause of death and acquired disability in children,23 it is essential for all physicians to play a role in curtailing these preventable injuries. As emergency physicians, we have the unique opportunity to care for children at a potentially ‘‘teachable moment’’; therefore, interventions should be sought that may be successful. Some of these interventions may be a simple addition to discharge instructions, or they may be multifaceted approaches
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that require education and the distribution of proven safety equipment. More research in the area of behavioral change counseling for injury prevention in a pediatric ED setting is essential. Although providing anticipatory guidance to families has generally been the responsibility of the primary care physician, this study shows how a pediatric ED can play a role in successfully restraining children from lower socioeconomic communities in beltpositioning booster seats by providing families with education and the appropriate car safety seat. The authors thank Judy Bean, PhD, for her assistance in calculating the sample size for the study and Stephanie Jauch, the study’s research assistant, for her efforts in helping enroll patients.
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11. Apsler R, Formica SW, Rosenthal AF, Robinson K. Increases in booster seat use among children of low income families and variation with age. Inj Prev. 2003; 9:322–5. 12. Longabaugh R, Minugh PA, Nirenberg TD, Clifford PR, Becker B, Woolard R. Injury as a motivator to reduce drinking. Acad Emerg Med. 1995; 2:817–25. 13. Johnston BD. Behavior change counseling in the emergency department to reduce injury risk: a randomized, controlled trial. Pediatrics. 2002; 110:267–74. 14. Posner JC, Hawkins LA, Garcia-Espana F, Durbin DR. A randomized controlled trial of a home safety intervention based in an emergency department setting. Pediatrics. 2004; 113:1603–8. 15. Quan L, Bennett E, Cummings P, Henderson P, Del Beccaro MA. Do parents value drowning prevention information at discharge from the emergency department? Ann Emerg Med. 2001; 37:382–5. 16. Zonfrillo MR, Mello MJ, Palmisciano LM. Usefulness of computerized pediatric motor vehicle safety discharge instructions. Acad Emerg Med. 2003; 10: 1131–3. 17. Isaacman DJ, Khine H, Losek JD. A simple intervention for improving telephone contact of patients discharged from the emergency department. Pediatr Emerg Care. 1997; 13:256–8. 18. Dunn C, DeRoo L, Rivera F. The use of brief interventions adapted from motivational interviewing across behavioral domains: a systemic review. Addiction. 2001; 96:1725–42. 19. Kruesi MJP, Grossman J, Pennington JM, Woodward PJ, Duda D, Hirsch JG. Suicide and violence prevention: patient education in the emergency department. J Am Acad Child Adolesc Psychiatry. 1999; 38:250–5. 20. Bernardo LM, Gardner MJ, O’dair J, Cohen B, Lucke J, Pitetti R. The DOG BITES program: documentation of growls and bites in the emergency setting. J Emerg Nurs. 2002; 28:536–41. 21. Nelson DE. Validity of self reported data on injury prevention behavior: lessons from observational and self reported surveys of safety belt use in the US. Inj Prev. 1996; 2:67–9. 22. Robertson AS, Rivara FP, Ebel BE, Lymp JF, Christakis DA. Validation of parent self reported home safety practices. Inj Prev. 2005; 11:209–21. 23. National Center for Injury Prevention and Control. Scientific data, statistics, and surveillance. Available at: http://www.cdc.gov/ncipc/osp/data.htm. Accessed May 3, 2005.
