Unintentional injuries involving children are the biggest single cause of child mortality in many countries of the world, and injuries resulting from motor vehicle crashes contribute significantly to this (WHO 2001). Available evidence suggests that child morbidity and mortality resulting from motor vehicle injuries can be largely prevented by correct use of appropriate child restraint (Gossman 1999; Forjuoh 1996). Yet, each year, millions are killed in such injuries, and thousands are permanently disabled. For example, motor vehicle injuries are the biggest single cause of mortality among children in the United States at every age after their first birthday, with a child being killed or injured every 90 seconds (CDC 2002a; NHTSA 1996). Children aged 4-8 years represent a special population for motor vehicle occupant protection. Having outgrown child safety seats designed for them, they ride frequently unrestrained, or strapped in adult seat belt systems for which they are not suited (CDC 2000; Flaura 2001; Winston 2001). Evidence shows that very few children aged 4-8 years use booster seats when riding in motor vehicles (AED 2001). More children aged 4-8 years die as occupants in motor vehicles crashes than from any other form of injury (CDC 2000). While policies and programs targeted at the promotion of child restraint use appear to be reducing injuries and deaths among children under four years of age (NHTSA 2000; Waller 2001; Zaza 2001), recent studies show that the figures for those aged 4-8 years are not improving (CDC 2002a; NHTSA 2000; IIHS 1999). For example, analysis of US data for 1994-1998 shows that very little change occurred in the death rate and restraint use among children of this age group killed in crashes over this period. Of those killed in 1994, only 35.2% (117 of 503) were restrained. Four years later, only 38.1% (n=201) of the 527 killed were restrained. A review of the data for 1999-2001 did not highlight any marked change (CDC 2002b). Although it is apparent that neither child occupant death rates nor restraint use is decreasing, it is pertinent to note that actual figures for restraint use might be even lower, based on the observation that police crash reports may overestimate restraint use (CDC 2000). Globally, motor vehicle injuries and deaths have been described as an issue of immense human proportions, an issue of economic proportions; an issue of social proportions, and an issue of equity - a problem that very much affects the poor (Ross 1999). According to a 1999 World Health Report (WHO 1999), 1,171,000 people are killed and 10 million are injured annually on the road. There is concern that, although these statistics are grim enough, they do not adequately represent the magnitude of this problem, given that in many parts of the world, motor vehicle injuries and deaths go unreported. Disproportionately high percentages of the annual deaths, injuries and permanent disabilities are borne by people in less developed nations (Murray 2001). Statistics show that, while less developed countries own only 32% of the world's vehicles, they account for 75% of the annual motor vehicle deaths. It is estimated that in the year 2020, motor vehicle injuries and deaths will become the third leading health burden worldwide (Murray 2001). Vehicular injuries involving children cause pain and suffering to children, and are an economic burden on affected families and the health system. Booster seats help to reduce the risk of 'lap belt syndrome' (Mickalide 2002; Thompson 2001; Durbin 2001) i.e. instances in which improperly fitting seatbelts actually cause serious injury to children in car crashes instead of protecting them (Pickler 2001; Halman 2002). In some crashes - for example, the shoulder belt that cuts across a child's neck (instead of the torso) and the lap belt that rides high on the child's abdomen - can cause severe internal injuries to the liver, spleen, intestines, and spinal cord (Hignston 1996). Public health and traffic safety organizations recommend that children aged 4-8 years should be restrained in booster seats (NHTSA 2000; CDC 1999; NTSB 1997; Am Acad Ped 1996). Thus, reducing motor vehicle occupant fatalities among this age group requires a search for effective strategies to promote booster seat use. An important factor in the protection provided by booster seats is the issue of correct use (Kunkel 2001). People may respond to regulatory and educational/promotional interventions to use booster seats but, if the seats are not properly fitted and correctly used, the benefits are negated and the potential harm remains (Winston 2001). As part of the efforts to address this problem, in the US for example, the Senate recently approved legislation encouraging states to adopt mandatory booster seat laws, and many states are beginning to implement this requirement (NHMHBC 2002). While this is an important step, in order to achieve sustainable change, evidence of the effectiveness of this approach is needed to justify resource use, identify strategies for optimizing benefits, and as a tool to promote wider implementation. Similarly, behavioral constraints against the use of booster seats must be equally tackled through education and promotion (AED 2001). Educational and promotional interventions that institutionalize positive behavior by choice are most effective in producing lasting behavior change (Mechanic 1999; Nelson 2002). To achieve optimum impact, however, legislative and educational/promotional interventions must be founded on valid evidence of what works and what does not. It is important for policy and practice that the potential benefits of all programs for promoting use of booster seats are evaluated, in order to inform optimal use of scarce resources. This review will assess the impact of various legislative, educational and promotional interventions to promote the use of booster seats among children aged 4-8 years. The review will include studies in which participants are individuals who transport children aged 4-8 years in motor vehicles. There is a strong rationale for the inclusion of studies involving all persons that transport children aged 4-8 years in a motor vehicle as against restricting this to parents/guardians of the children. A recent survey of motor vehicle occupant safety (Block 2000) found that more than four out of ten drivers (44%) had in the past year driven a motor vehicle with a child under 6 years of age as a passenger. More than half of these (28%) did not live with a child within this age range, but nonetheless, had driven a child of that age in the past year. Synthesizing evidence of effects of the various approaches will help to inform policy and practice, justify use of resources, train health professionals, and facilitate design of community-based prevention programs that are effective. (Author/publisher)
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