County of San Diego Division of Emergency Medical Services

EMS

Impact of a New Booster Seat Law

Barbara Stepanski, MPH

Isaac Cain, MFS; Louise Nichols

Leslie Upledger Ray, MA, MPPA

David Thompson; Roxanne Hoffman MEd

Angela Fix, MPH; Edward Castillo,PhD, MPH

Alan Smith, MPH

County of San Diego Division of Emergency Medical Services

EMS

Background Seat Belt Legislation

• Historically legislation has influenced seat belt use in motor vehicles (MV)– 10%-15% from the time safety belts were first installed

in MV (1950s) until the early 1980s

– Increase to 42% by late 1980s as a result of the passage of seat belt laws in 31 states

– Increased to 62% by 1992 - more states passed laws, national enforcement and public education

– 68% in 1996 ranging from 87% in CA to 43% in ND

– 75% in 2002

County of San Diego Division of Emergency Medical Services

EMS

BackgroundChild Safety Seat (CSS) Legislation

• First laws were generalized to all MV occupants (MV seat belt designed for occupants of a minimum size of 4’9” and approximately 80 lbs)

• First child specific seat belt laws – 1979 TN, 1983 CA

• Prior to 2002 in CA - No CSS law in place for children too large for infant or toddler seats and too small for MV (adult) seat belts

• 2002- CA’s new law extended protection for child passengers to age 6 or 60 lbs (need to meet only one criteria) (not considered maximum protection)

County of San Diego Division of Emergency Medical Services

EMS

Background

• National CSS use estimates (NHTSA)– infant and toddler - 91%

– booster seat use - 10%

• Booster seat use is low for children who have outgrown their infant/convertible/forward-facing seat (Partners for Child Passenger Safety)

– 29% of 3YO are inappropriately graduated to a booster seat

– 16% of 3YO are inappropriately moved to a MV seat belt

– 83% of 4-8YO are inappropriately moved to a MV seat belt

County of San Diego Division of Emergency Medical Services

EMS

Background

• In the San Diego Prehospital setting– 8% of children 0-9 seen by

paramedics/EMTs are due to MV crashes• 50% 0-4YO are not restrained in a child seat

– 11% of 0-4YO are completely unrestrained

• 20% of 5-9YO are completely unrestrained

County of San Diego Division of Emergency Medical Services

EMS

Data Source

• Buckle Up San Diego/San Diego Safe Kids Coalition child safety seat inspection events, 1999 - 2002– 69 inspection events– 1707 seat positions inspected

County of San Diego Division of Emergency Medical Services

EMS

CSS Inspection Logistics

• NHTSA certified technicians and instructors

• Each inspection took approximately 30 minutes

• Various locations (schools, retail stores, health fairs, etc.)

• Weekend and non-school hour times

• Volunteers

• Standard data collection tool

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Population Density0 - 204205 - 408409 - 612613 - 816817 - 10211022 - 12251226 - 14291430 - 16331634 - 18371838 - 2042

$T Inspection Sites

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POPULATION DENSITY with EVENT LOCATIONS0 - 9 Year Olds by Subregional Area

Source: County of San Diego, Health andHuman Services Agency, Division of

Emergency Medical Services

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I-5

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SR-94

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10 0 10 20 Miles

N

MORENA TOYS R USCarseat Inspection Participant Households

Population Density0 - 204205 - 408409 - 612613 - 816817 - 10211022 - 12251226 - 14291430 - 16331634 - 18371838 - 2042

Major Roads5 by 5 mile Morena buffer

#S Morena Participants

Source: County of San Diego, Health andHuman Services Agency, Division of

Emergency Medical Services

County of San Diego Division of Emergency Medical Services

EMS

Distribution of Seat Type

• Rear-Facing (764, 45%) – Infant with or without a base– Convertible

• Forward-Facing (668, 40%)– 5-Point Harness – T-Shield – Tray Shield – Toddler/Booster – Integrated Seat

(31 were missing seat types)

• Belt Positioning Boosters (BPB) (87, 5%)– High-back

– Backless

• Shield Booster Seats (11, .7%)

• Vehicle Safety Belts (38, 2%)

• Other Child Restraint (3, 0.2%)

• No Seat (105, 6%)

County of San Diego Division of Emergency Medical Services

EMS

Results Pre & Post Law Comparison

Seat Inspected Pre 2002 Law Post 2002 Law

Belt Positioning 58 29

Shield* 11 0

Total 69 29

% of seats inspected 5 10

Avg per month 2.23 9.67

* No longer recommended – does not provide upper body protection

County of San Diego Division of Emergency Medical Services

EMS

Results

• Booster seats– 89% BPB– 11% Shield (None

Post 2002)

• Inspection Criteria – 3 measures -BPB– 7 measures -Shield

County of San Diego Division of Emergency Medical Services

EMS

Results – Inspection Criteria for Belt Positioning Boosters

81

968483

93 91

0

20

40

60

80

100

lap/

shld

belt

s cor

r pos

itione

d

within

ht &

wt r

ange

safe

ty be

lt ro

uted

corre

ctly

Pre 2002Post 2002

% that meet criteria

County of San Diego Division of Emergency Medical Services

EMS

Results – Inspection Criteria for Shield Boosters

0102030405060708090

100

shie

ld sn

ug a

gain

st ch

ild

within

ht &

wt r

ange

only

lap

belts

ava

ilable

safe

ty be

lt ro

uted

corre

ctly

seat

tight

in v

ehicl

e

lock

ing c

lip u

sed

corre

ctly

safe

ty be

lt loc

ked

% that meet criteria

4 additional criteria added to revised 2002 form however no shield boosters were inspected using this form

County of San Diego Division of Emergency Medical Services

EMS

Results - Age

0102030405060708090

100

2 3 4 5 6 7 8

BPB Pre 2002

BPB Post 2002

Shield Pre 2002

Age

%

County of San Diego Division of Emergency Medical Services

EMS

Results - Weight

0102030405060708090

100

Shield Pre 2002 BPB Pre 2002 BPB Post 2002

< 40

40-44

45-49

50-54

55-59

60+%

County of San Diego Division of Emergency Medical Services

EMS

Results - Siblings

0

20

40

60

80

100

Pre 2002 Post 2002

%

County of San Diego Division of Emergency Medical Services

EMS

Vehicle Safety Belts (VSB)

0

10

20

30

40

50

60

70

80

90

100

weight <60 # age < 6

Pre 2002

Post 2002

%

County of San Diego Division of Emergency Medical Services

EMS

Results• 27% of booster seats demonstrated at least one

error, most frequently:– Shield

• correct use of the locking clip (33.3% correct) • vehicle belt holding seat tight, 1 inch test (37.5% correct)

– BPB• lap/shoulder belt correctly positioned (82% correct)

• Significant difference in misuse by booster type – 21% misuse for BPB (both Pre and Post 2002 Law)

– 73% misuse for Shield Booster

– 3.5 times more likely to have an error using a Shield vs. a BPB (RR = 3.52)

County of San Diego Division of Emergency Medical Services

EMS

Results

Number of booster seats inspected increased

Slight increase in age of children who’s seats were

inspected

Slight increase in number of booster seats inspected

w/o younger siblings

Number of Shield boosters inspected decreased

VSB inspections for children <60 lbs or <6YO decreased

Percent of misuse among BPB remained the same

County of San Diego Division of Emergency Medical Services

EMS

Conclusions

• Efforts to make CSS installation easier include:– Universal LATCH system– NHTSA’s “Ease of Use” CSS rating system gives

an “A” “B” or “C” grade for:• Pre-assembled or consumer assembly required• Clarity of labeling on seat• Clarity of written instructions on proper use• Ease of securing child in seat• If seat has features that make installation in vehicle easier• and a overall grade for ease-of-use

County of San Diego Division of Emergency Medical Services

EMS

Conclusions

• In comparison to other seat types (forward and rear facing) booster seats have a higher percentage of correct use

• Law has increased awareness/motivation resulting in more booster seats being inspected. However installation errors stayed the same, indicating the need for public health education on “proper use” of booster seats

County of San Diego Division of Emergency Medical Services

EMS

For more information contact:

Barbara M. Stepanski, MPH

County of San Diego HHSA

Division of Emergency Medical Services

6255 Mission Gorge Road

San Diego, CA 92120

phone - (619) 285-6429

barbara.stepanski@sdcounty.ca.gov