When treating is not enough: The roles of health care providers in prevention and control of childhood motor vehicle crash injuries

Obesity, diabetes, cancer – these are what most parents believe are the leading health risks for children in Canada (1). Yet injuries, especially those on our highways, are the number one killer of Canadian children and youth. As the surveillance study by Santschi et al (2), and numerous case series and reports before them have all shown, children younger than nine years of age are particularly vulnerable to catastrophic injuries in a motor vehicle crash, especially when not properly restrained (2–4). Why the disjunction between perception and reality? What can we, as health care providers for children and youth, do to reduce this disjunction and these devastating injuries?

Despite the wishes of parents to keep their children as safe as possible, and widespread efforts over the past decades to educate the public on the importance of childhood motor vehicle restraint use, including booster seats, significant deficits in knowledge over what to use and when to use it still exist (unpublished data). Reasons for these deficits are likely as diverse as the knowledge gaps themselves, varying from the persistence of older guidelines, discrepancies in recommendations from different sources and gaps in legislation, to the effects of diverse socioeconomic and demographic factors.

Education of caregivers is vital to encourage the use and understanding of the benefits of booster seats and other childhood motor vehicle restraint systems. Caregivers often prefer to get information on such safety issues from their family physicians and paediatricians (unpublished data). Primary care physicians are key voices in educating care-givers; thus, they too must be knowledgeable and able to deliver consistent and current recommendations. Physician knowledge of automobile safety for children may be lacking or may not conform to current recommendations, and counselling in this area may be inconsistent (5,6). Associations, such as the American Academy of Pediatrics, regularly publish guidelines for counselling parents on various injury prevention issues, including childhood motor vehicle restraints, but the uptake of the guidelines is unknown (7,8). Moreover, physician counselling in this area has only been shown to have short-term efficacy, with no long-term changes in caregiver behaviour (9). Further studies are needed to determine the efficacy of physicians as vehicles for educating caregivers on childhood motor vehicle restraints.

However, education alone is simply not enough. Competing factors beyond knowledge frequently result in caregivers not following what they have been told is best. In Nova Scotia, lower socioeconomic status of families has been shown to influence incorrect restraint practices for children appropriate for forward-facing car seats (unpublished data). This was also noted by Winston et al (10), who demonstrated that among caregivers having been involved in a crash, a lower parent driver’s education level and a lower household income level was associated with a higher risk of suboptimal restraint use for children one to three years of age. Inconvenience associated with the use of booster seats and their child not wanting to use it has been reported by parents (11). In addition, most caregivers possess an immunity fallacy, characterized as a reduced perception of risk of injury in the case of a motor vehicle crash involving their children (11,12). Subsequently, they may perceive the cost or inconvenience of using a certain restraint system as outweighing any perceived benefit in the form of reduced risk of injury in a motor vehicle crash (11,13). These factors are likely not mutually exclusive. Parental misconceptions about the risk of injury, in addition to a lack of awareness of best practices, have been identified as barriers to optimal restraint for children five to nine years of age (14,15).

Primary child health care providers should play a role in identifying and eliminating these barriers for the families they treat. Advocating for car and booster seat loaner programs available to those unable to afford their purchase, and car seat check-up clinics for those not confident in their use, is just as vital as advocating for local immunization policies and public health clinics (16). Counselling caregivers on balancing injury risks with perceived inconvenience, in favour of safety, is as important as promoting physical activity and healthy eating.

As professionals and leaders in the community, primary health care providers must also transfer their efforts, knowledge and responsibilities beyond the walls of the office, and advocate for evidence-based policies that reflect and enhance the recommendations they give to their patients. The evidence of positive effect of legislation in improving knowledge, and the use of booster seats, has recently been shown in 16 states, where booster seat use increased among children six and seven years of age by 3.7-fold, as well as in Washington, DC (USA) (17). Gunn et al (18) also noted that booster seat legislation resulted in a 34% increase in booster seat use in the state of Tennessee (USA). Currently, mandatory use of booster seats has been legislated by only seven of Canada’s 13 provinces and territories. The evidence provided by Santschi et al (2) demonstrates that this is simply not good enough (2). Advocacy by health care professionals in influencing injury prevention and control policy has been shown to effect legislative change and reduce injury rates (19). This is a responsibility of those charged with caring for our children and youth. This is an obligation which must be accepted and acted on to ensure consistent messages and motor vehicle safety across this country for the most precious cargo that we carry on our roads.