Evaluation of a Distribution, Education, and Awareness Intervention for Child Passenger Safety in Lebanon – a Low- and Middle-Income Country Setting

Abstract

Background:

The Eastern Mediterranean Region suffers disproportionately from pediatric traffic-related injuries. Despite governmental laws, Lebanon – an eastern Mediterranean country – has low child restraint (CR) use prevalence. This study examined the impact of utilizing car seat Distribution, and child passenger safety Education and Awareness intervention to improve child passenger safety knowledge and practices amongst caregivers.

Methods:

This study recruited Lebanese caregivers with one child or more, using a 4-wheel motor vehicle, and not using a car seat. The intervention comprised an educational session followed by a car seat or booster seat distribution and installation check by a certified child passenger safety technician. A baseline assessment questionnaire was used to identify reasons for prior CR non-use. A child passenger safety knowledge test was administered before, immediately after, and three months post-intervention to assess child passenger safety knowledge retention and compare it to the baseline using the conditional logit model for pre-post interventions.

Results:

Fifty-eight participants underwent the intervention. Affordability was identified as the primary reason for car seat non-use. Three months after the intervention, compliance with CRs use was reported at 100%, and correct responses on the knowledge test significantly increased (p<0.05) for all items except for harness tightness (p=0.673).

Conclusion:

Our child passenger safety intervention resulted in improved knowledge and increased self-reported use of child restraints in a caregivers’ cohort in Lebanon. Further efforts should address sociocultural and economic barriers and the lack of local child passenger safety technicians to mitigate the region’s pediatric road traffic injury and death toll.

Introduction

Road traffic injury (RTI) is the leading cause of preventable deaths in low- and middle-income countries (LMIC) and the sixth leading cause of disability-adjusted life years globally (1, 2). Children are vulnerable road users, whereby child transport injuries and deaths constitute a significant public health issue (3). Special attention is directed toward the Eastern Mediterranean Region, which, despite housing only 5% of the world’s vehicles, bears the highest burden of all-age fatal transport injuries and the highest fatal pediatric transport injuries globally. (4, 5).

Lebanon is one of the few countries within the EMR that has enacted a child restraint law (i.e., law 243, which mandates car seat use for children under the age of 5). Nevertheless, the child road injury burden is considerably higher than other countries globally (4, 6, 7). According to the Road Safety Facility’s recent statistics, the rate of RTI deaths in Lebanon was estimated at 18.1 per 100,000 population (WHO estimate for 2016) (8). Data on child transport injuries are scarce due to data underreporting and the lack of national injury surveillance systems (9). Nonetheless, existing evidence on the extent of the child RTI burden in Lebanon confirms that children aged 0 – 5 are the most susceptible to fatal road injuries (9).

Road safety interventions have been widely studied to help nations curb child transport injuries’ frequency and severity. Despite the abundance of child restraint (CR) interventions, their implementations are mainly adopted and thoroughly researched in high-income countries (10, 11). These interventions include providing caregivers with CRs, education on various mediums on child safety, and hands-on training on the proper CR utilization offered by certified child passenger safety technicians (CPSTs) (12–16). The United States Centers for Disease Control and Prevention (CDC) and the Community Preventive Services Task Force have highly recommended the multifactorial approach for child road safety for over a decade (17). In Lebanon, research to evaluate the acceptance and efficacy of such interventions is limited. This could be partially attributed to the poor road safety law enforcement that results in low compliance with using CR systems (9, 18).

This study aims to determine whether the distribution, education, and awareness (DEA) intervention can improve child passenger safety knowledge and increase CR adoption, as well as to identify the main reasons for CR non-use in an LMIC setting. We hypothesize that a distribution plus education/awareness approach would enhance CPS knowledge and practice among child caregivers. This study will further identify the main barriers to CR adherence and potential efforts that could be made to improve CR use based on recommendations by caregivers. Our findings represent a stepping stone towards spreading road and CPS knowledge among parents and caregivers and identifying urgent issues to be addressed by researchers and injury prevention programs.

Methods

Study Design

This study followed a pre-post interventional design with primary data collection. Data were collected from different regions across Lebanon (i.e., South, North, and Beirut). The study was conducted during the month of July 2022. The sampling procedure followed a non-probability convenience process where participants were recruited through referrals from pediatricians or academics at various pediatric clinics and healthcare institutions in each geographic region. The total number of participants from the convenience sample was reached based on two factors: 1) The limited number of available child restraints for this study and 2) Participant availability to attend a workshop during a designated day and time. Consent to participate was obtained from all participants before administering the questionnaires.

Parents or caregivers were included if they had at least one child under the age of 9 years, were Lebanese residents, used a 4-wheel vehicle as the primary mode of transportation, and were not using a car seat before or at the beginning of this study.

Patient and Public Involvement

Patients and/or the public were not involved in the design, conduct, reporting, or dissemination plans of this research.

Intervention Model

The intervention model included two main components: the educational/awareness and the child car seat distribution/installation facilitated by the study CPST. The study CPST was a certified safety technician at Cincinnati Children’s Hospital Medical Center in Ohio, USA, and acted as the source of knowledge and provided technical demonstrations and expertise related to the proper use and installation of car seats and booster seats in this study. The car seats and booster seats utilized during the workshops were the programmatic convertible car seats. Restraints were made available to all participants up to the age of nine. The restraints employed underwent crash testing by in accordance with Federal Motor Vehicle Safety Standards 213 (FMVSS213), as mandated by the National Highway Traffic Safety Administration in the United States. The educational component entails raising awareness and informing participants about the alarming status of child road injuries in Lebanon, followed by a review of car seat types and their proper use. The installation component comprised giving car seats to participants and providing instructions on their proper installation in vehicles. A live demonstration utilizing the study’s car seats and training dolls was provided by the study CPST. This step was followed by the installation of the car seats by the parents/caregivers, checked by the CPST to confirm compliance with installation standards. The study educational components were delivered in English, with Arabic interpretation provided by the study team members throughout the workshop. Car seat properties were selected according to the proper seat specifications for the child(ren)’s age(s) and size(s). The CPST identified the appropriate child restraint according to manufacturer specifications and best practice child passenger safety recommendations in accordance with the National Child Passenger Safety Technician Certification Training curriculum and Safe Kids Worldwide. Regarding legislative guidelines, we adhered to Lebanese law, which prohibits children under the age of 10 from riding in the front seat and mandates that children under the age of 5 must ride in a car seat in the back seat. Each household received a maximum of two car seats if they had more than one child. The car seats provided were tailored to their children’s age and size. To prevent undue influence, participants were informed that they would need to return the car seats after the study follow-up period if they chose not to use them. However, if participants reported they were still using the car seat(s) or booster seat(s) at follow-up, they were informed that they could keep them at no cost.

Tool

The CPS knowledge test was adapted from the 2020 version of the National Child Passenger Safety Technician Certification Training curriculum as well as the car seat manufacturer’s instructions for proper car seat and booster seat use. It was then verified by the study PI (SA) and the CPST (MP) based on their professional expertise in the field (detailed survey questions in Appendix 1). The survey questions were categorized into three main themes: general safety, positioning, and knowledge of Lebanese law. The general safety category included the child’s safest position, the car/booster seat’s main purpose, and the safety of adding pillows/cushions to a car seat. The positioning category included harness tightness, harness slot level (rear-facing), and front seat adjustment to brace the car seat. Bracing is a common form of car seat misuse that CPSTs investigate during car seat checks because this practice is not allowed by most manufacturers, including the manufacturer of the seats used in this study. The Lebanese law category included the back seat age and the car seat age-related laws. Study team members MP and SA ensured the “face and content” validity of the survey questions through a back-and-forth discussion to reach a consensus.

Data Collection

Questionnaires were given to participants upon arrival to the workshop-designated area. The workshop venues were academic classrooms or outpatient offices located in three different regions in Lebanon: North, South, and Beirut. Baseline demographic information, a baseline questionnaire about restraint use by parents, and a child passenger safety knowledge test were administered. In addition, the participants were asked about the reasons for not using a child restraint before initiating the study interventions through a group conversation guided by an open-ended question “Why don’t you use road child safety restraints for your children, state the reasons?” The reasons were documented and reported by the research assistant during the conversation and were validated for correctness with the participants at the end of the discussion. The collected qualitative data were analyzed, and the emerging themes were noted by the study research assistant and used to offer recommendations aimed at promoting the dissemination of knowledge and behaviors regarding car safety awareness that were also reported. Immediately after the interventions, the participants completed the CPS knowledge post-educational sessions test. This test questionnaire was administered three months post-intervention through a follow-up phone call, and participants were asked if they were still using the CPS seats three months after the intervention.

Statistical Analysis

The data were initially entered into RedCap and subsequently exported into an Excel worksheet. The answers to the open-ended questions (reason for not using CRs and recommendations for increasing knowledge and improving CR use behavior) were categorized and coded. Along with the quantitatively collected information on baseline characteristics, background use of vehicle safety restraints, and the knowledge tool, data were imported to STATA statistical software for analysis. A descriptive analysis was conducted to provide an overview of the participant’s demographic information. Continuous data were presented as mean ± standard deviation, and categorical data were presented as frequencies and percentages For visual presentation, bar graphs were plotted to illustrate the response pattern for the CPS knowledge test. The primary outcome was the correct answers to the knowledge test items for all participants regardless of the restraint received (car seats or booster seats). Additionally, a pie chart was generated to show the different reasons for not using CRs before the study entry. Inferential statistics were then employed to determine whether there were statistically significant differences in correct responses to the knowledge check test across multiple time points, including baseline and three months post-intervention. Specifically, the conditional logit model was utilized to assess for significant shifts in the test responses.

Ethics approval

The study obtained human research ethical approval from the American University of Beirut Institutional Review Board (IRB ID: 2021–0300).

Results

A total of 58 individuals participated in the study at baseline and underwent the DEA intervention. Demographic and baseline characteristics are presented in Table 1. Most of the participants resided in the South region of Lebanon (~50%), were females (~70%), graduated from university (~45%), and only 25% had a monthly salary exceeding $260 (at the 75^th percentile), and with seven individuals (12%), reporting a monthly income exceeding 1,000$. The majority of the caregivers indicated that they wear seat belts in vehicles (67%) and place their children in the backseat of the vehicle (66%) when commuting (Figure 1). At the three-month follow-up point, 54 participants responded, all confirmed using the car seat (100%) and all were then informed they were allowed to keep the car seat at no cost.

Table 1:

Demographics and baseline information of the sample of 58 Lebanese caregivers recruited in Lebanon in July 2022

	N=58*
Participant location (n=58) South (Sour) South (Nabatieh) North (Tripoli) Beirut	14 (24.14%) 15 (25.86%) 18 (31.03%) 11 (18.97%)
Vehicle model year (n=52) Before 2000 2000 – 2010 2010 – 2019	10 (19.23%) 16 (30.77%) 26 (50%)
Participant relation to child(ren) (n=54) Mother Father Other Aunt Brother	37 (68.52%) 15 (27.78%) 2 (3.70%) 1 (50%) 1 (50%)
Number of children per household (n=57) 1 2 3 4 5 7	24 (42.11%) 16 (28.07%) 12 (21.05%) 3 (5.26%) 1 (1.75%) 1 (1.75%)
Children under the age of 5 per household (n=57) 0 1 2	3 (5.26%) 40 (70.18%) 14 (24.56%)
Number of children participating in the study per household (n=58) 1 2	45 (77.59%) 13 (22.41%)
Participant 1 Age, months (n=51)	27.73±24.32
Participant 2 Age, months (n=12)	35±23.87
Pregnant (n=53) Yes No Not applicable	4 (7.55%) 32 (60.38%) 17 (32.08%)
Parent’s age	33.81±7.34
Gender of parent attending the workshop (n=57) Female Male	40 (70.18%) 17 (29.82%)
Highest education level completed by the parent attending the workshop (n=57) Didn’t finish high school Institute or trade school Graduate high school Graduated University Graduate degree	10 (18.87%) 6 (11.32%) 4 (7.55%) 24 (45.28%) 9 (16.98%)
Income, USD (n=51)	353.57±566.66

Figure 1.

Baseline Assessment of Car Seat Restraint Use by a Sample of 58 Lebanese Caregivers in Lebanon in July 2022

At the baseline CPS knowledge check, 90% of the participants were aware of the child’s safest position and the car/booster seat purpose in a vehicle. Over half of the participants answered incorrectly to six of the eight administered questions (Figure 2). These questions included the safety of adding pillows/cushions to the car seat (%correct response=46%), proper harness tightness (33%), adequate harness slots level (30%), Lebanese laws for the back seat and car seat age (41% each), and the passenger front seat position (48%).

Figure 2.

Child Passenger Safety Knowledge Check of a Sample of 58 Lebanese Caregivers in Lebanon in July 2022

Three months after the intervention, the percentage of correct answers to the general safety category increased to 100%, namely the safest position and the car/booster seat purpose in a vehicle.

Most participants correctly answered most of the other categories’ questions immediately after the intervention. Three months post-intervention, correct responses increased significantly to four of the eight test questions compared to baseline responses (Figure 2). The percentage of correct answers increased except for one question addressing the proper harness tightness in the positioning category (33% → 51% → 30%, p=0.673).

The workshop series demonstrated participants’ strong interest in child passenger safety. The critical issues that emerged during group discussions included affordability, lack of awareness of the magnitude of child passenger injuries in Lebanon, lack of knowledge about the importance of child passenger safety, and lack of enforcement of child passenger safety laws. The primary reason for not having a car seat was its high price, which participants could not afford (Figure 3).

Figure 3.

Primary Reason for Not Using a Car Seat by a Sample of 58 Lebanese Caregivers in Lebanon in July 2022

As part of the ongoing discussions during the workshop, participants were asked to provide suggestions to help disseminate car safety awareness knowledge and behaviors. Some participants suggested using social media to improve public awareness, and many participants were eager to share pictures of their children in the car seat on social media during the workshop. Several participants show interest in using convertible car seats instead of rear-facing ones for affordability and long-term use. They were amenable to their use after being informed that the study car seats were suitable for children weighing 2.3 kg (5 lbs.) or greater. Agreeing to use a rear-facing car seat was challenging for some participants. They mentioned that the child becomes upset once restrained, particularly for children past the newborn stage who were unaccustomed to riding in a car seat.

Discussion

This study represents, to the best of our knowledge, the first multifaceted child road safety intervention model in the Eastern Mediterranean Region. The study incorporates education and awareness coupled with the distribution of car seats and interactions with a CPST into the interventional DEA, intending to increase the knowledge and use of car seats among caregivers. We contextualized this intervention not only via translating the training and the materials into Arabic, the language of the LMIC of this study, but through partnering and collaborating with local researchers and practitioners during the intervention delivery. This collaborative effort ensured we were able to raise awareness on the burden of child road injuries at a national level and tailor the intervention disseminated to the population of interest in a culturally appropriate and relevant manner. This study implemented an established standard for improving CPS practices in an LMIC setting and identified barriers to the lack of use before the intervention and issues with sustained use post-intervention. With the limited empirical data on the adaptability of CPS interventions in the EMR region, this study contributes to closing the knowledge gap and enhancing CPS practices outside high-income countries (14, 19).

This study showed an improvement in all three CPS knowledge assessment test categories following the implementation of the DEA intervention. It is noteworthy to highlight caregivers’ positive reception and enthusiastic engagement in response to the DEA intervention. It is also worth noting that participant recruitment for the available harness car seats reached capacity prior to recruitment for the booster seats. This may indicate a greater awareness in the population for protecting the youngest and most vulnerable passengers, or that further efforts should be provided to educate and advocate for booster seat use may be warranted, or both, though we acknowledge this observation could be a bias towards younger passengers based on our convenience sample.

Our findings align with existing studies conducted outside the EMR and support the evidence for improved CPS knowledge following a multifaceted intervention program. Comparably, a study in China indicated that car seat distribution plus education intervention significantly outperformed the education-only intervention in terms of both retained knowledge and sustained car seat use (12). Similarly, studies in the USA recognized that interactions between caregivers and CPSTs significantly improve car seat use while reducing its misuse (20, 21). Budziszewski et al. conducted a similar intervention and reported substantial improvement in CPS knowledge (22). However, they observed significant improvement in “harness tightness” within the “positioning” category. This discrepancy might be attributed to shorter assessment periods in this study compared to three months, which allowed for better knowledge retention. While there is a scarcity of distribution plus education studies conducted within the EMR, we examined outcomes for related regional studies that adopted any strategy for child car seat safety intervention. Few education-only intervention studies were implemented in EMR that resulted in safer road behavior, though not necessarily using car seats. A study in Jordan demonstrated that an evidence-based educational program on child road safety improved child car restraint usage and increased caregivers’ compliance with restraining children into a vehicle’s back seat (23). A common pattern was observed in this study with a significant increase in knowledge related to the back seat age law from 41% at baseline to 70% at follow-up. While in this study, all caregivers were still using the car seats at follow-up, Kilani et al. reported that only 11% (one participant) of those who did not have a car seat initially acquired one after the education-only training (23). Grivna et al. found that only 30% of participants who underwent an education-only intervention in the UAE purchased a car seat (24). These results suggest that education alone is not sufficient to encourage caregivers to buy car seats. None of the existing studies mentioned whether a CPST administered the educational intervention, as in this current study. The interaction with a CPS technician in our interventional model is believed to have positively influenced our results.

This study revealed several factors contributing to the lack of use of car seats in Lebanon. These factors included concerns about affordability, the misconception that placing the child on a parent’s lap is safer than a CR, the absence of law enforcement, and reluctance to install and position the car seat, especially during short road trips. The baseline assessment of road safety restraint usage by parents indicated that car seats were not commonly used during parents’ childhood, which might partially explain their unawareness of their importance. This result is consistent with the findings reported in the literature regarding seat belt usage in Lebanon (25). Moreover, participants exhibited limited awareness of the risks associated with the non-use of child car restraint systems, which could be an essential barrier to investing in a car seat and using it appropriately. Comparably, a study in China utilized the theory of planned behavior to gain insights into parental decision-making processes related to car seat use (26). They observed that the parents’ perceived benefits and barriers are associated with increased or reduced car seat use. Similarly, Simpson et al., demonstrated that despite parents being aware of the added benefits of booster seats over seat belts alone, reasons for non-use were primarily influenced by risk perceptions and awareness levels (27). This pattern was evident in our study, where most participants correctly answered two items under the general safety category, safest position and car/booster seat main purpose (91% and 96%, respectively), but not the questions belonging to the positioning and knowledge of Lebanese Law categories. In this study sample, car-seat non-use could be attributed to caregivers’ perceptions of child CPS.

The results of this study confirmed our hypothesis that a distribution plus education/awareness approach would enhance CPS knowledge and practice among child caregivers. Despite the small-scale nature of this study, adopting a distribution plus education intervention in LMICs like Lebanon holds promise. The caregivers’ evident receptiveness, coupled with a strong willingness to acquire knowledge and modify their behaviors, underscore the promising potential of similar initiatives in LMICs. Our results further call for policymakers and traffic safety experts to adopt safety strategies and enforce safety laws in the country. In addition, collaborative efforts with relevant local ministries (Ministry of Health) to educate caregivers about CPS measures and considerations are crucial for significantly enhancing the use of CPS car seats. It is highly recommended to triangulate the results from this DEA study with different interventions within a multifaceted prevention program at a larger and more comprehensive scale to target and address child road safety intentionally.

This study has some strengths and limitations. One of the main strengths of this study lies in the fact that such a multifaceted intervention has not been applied in the region before. Moreover, loss-to-follow-up was minimal (<5%), which, in addition to being helpful for our statistical inferences, reflected that caregivers were interested in the intervention and its outcomes. This study has some limitations. First, participation in this study was entirely voluntary. Such an approach may have introduced bias in creating a cohort more amenable to car seat use and education. Second, this study was limited to some regions in Lebanon, but to our knowledge, it represents typical Lebanese families with young children interested in CPS. Third, the salaries reported may not necessarily represent the Lebanese population’s income. Fourth, the questionnaire used in this study did not include technical questions related to the use of booster seats because most people are unfamiliar with the booster seat concept, so we based our questionnaires on familiar concepts. Further research should make efforts to explore knowledge and perceptions regarding all types of child safety seats. Fifth, the self-reported nature of data collection may have resulted in reporting and/or social desirability bias in the outcomes of this study which could have influenced our results. At follow-up, this method might have led to an overestimation of CRS use since follow-up was conducted over the phone. To address this concern in future studies, incorporating a social desirability question into the knowledge test, administering tests anonymously, employing self-reported standardized questionnaires, and conducting in-person checks of proper CRS usage by caregivers could minimize such biases. Due to constraints in study design and limited funding, we were unable to conduct follow-up assessments to evaluate the long-term sustainability of the intervention outcomes. Additionally, we did not assess the participants’ intention to continue using restraints after the completion of the study. Furthermore, it is worth noting that the study was conducted at a time when Lebanon was suffering from economic instability coupled with the challenges of the COVID-19 pandemic, which imposed considerable financial strains on families, as reflected in the reported salaries (only 25% of the studied sample has a monthly salary of >$260 with a sizeable range). Finally, the sustainability of this type of intervention in terms of cost and personnel is undoubtedly a challenge for future work in under-resourced settings. However, we believe the results of our study underscore the amenability of this type of intervention in LMICs and can be used as a foundation to advocate for increased funding, perhaps in forms of subsidies for child restraints, and/or the training of child passenger safety personnel at the governmental and non-governmental levels.

Conclusion

Child passenger safety is a major yet neglected health problem in many EMR countries. Lebanon, one of the few countries in EMR with CR law, lacks awareness and use of CRs in vehicles. This study showed that a car seat distribution plus CPS education intervention was significantly associated with higher self-reported usage of CRs and enhanced CPS knowledge after three months post-intervention. Furthermore, child caregivers exhibited receptivity to the program and its objectives. Consequently, prioritizing CPS campaigns facilitated by CPSTs to increase child restraint use in Lebanon holds promising prospects to potentially alleviate the region’s toll of pediatric road traffic injuries and fatalities. Nonetheless, potential future research should examine the differences in knowledge retention between parents who receive a booster seat vs. a convertible car seat or receive both. Implementation research and programs will benefit from the results of this study and build upon its findings for a more extensive interventional program and longer follow-up periods.

Key Messages.

What is already known on this topic

Distribution plus education intervention is an established best practice for improving child passenger safety practices. This type of intervention has been studied primarily in high-income and Western countries.

What this study adds

Our study shows that a distribution plus education intervention facilitated by a certified Child Passenger Safety Technician can be effective at improving caregiver-child passenger safety knowledge in a low- and- middle-income country with low overall compliance with restraint laws and use.

How this study might affect research, policy, or practice

This study provides evidence that distribution plus education interventions should be undertaken in low- and- middle-income countries and the Eastern Mediterranean region to improve child passenger safety knowledge and increase safety seat uptake.