CRS Misuse and ISOFIX and LATCH CRS Use in Israel Introduction

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1 Ref: CRS Misuse and ISOFIX and LATCH CRS Use in Israel Sharon Levi2Fi, Yishay Hamenachem, Ayelet Gilad, and Michal Klein Proceedings of the 10th Protection of Children in Cars International Conference, TUV SUD December 6-7, 2012 Munich, Germany Introduction In Israel the leading cause of death from unintentional injury for children and adolescents age 0-17 is involvement in a motor vehicle crash. Fatalities are highest for children as passengers at 33% of the total motor vehicle fatalities. On average approximately 218 children age 0-9 were hospitalized in trauma units in due to injuries as passengers in a motor vehicle crash. Children injured in a motor vehicle crash were more likely to be hospitalized at ISS>16 (Ivancovsky and Kislev, 2011). A primary method to prevent injuries to children as passengers in vehicles is appropriate use of occupant restraints according to the age, weight and height of the child. Studies in Europe and the U.S. have shown that use of a safety belt is preferable to no restraint at all; however the use of a child restraint system (CRS) significantly reduces injuries among child passengers (ETSC, 2009; NHTSA 2009; Durbin et al. 2005). Child safety seats reduce fatalities among infants (7) and toddlers (54%). Booster seats have been proven to reduce serious injuries among children age 4-7 (59%) in comparison to safety belts alone (Elliot et al. 2006). The Israeli law, enacted in 2004, requires a rear facing seat until age 1, a forward facing seat until age 3, and a booster seat until age 8. The law allows children in a CRS in the front seat as long as there is not an active air bag. In 2012, the safety recommendations issued by Beterem-Safe Kids Israel were updated and are more rigorous than the law, specifically a rear facing seat until age 2, a forward facing seat until age 4, and a booster seat until age 9. Israeli regulations require import of CRS models with European or U.S. safety standards. The rate of CRS use in Israel has increased in the last decade, however in spite of the law and the proven effectiveness of CRS in preventing injuries; usage rates in Israel are still lower than in many countries in Europe. A national observational survey of CRS use in Israel in 2010 found that 15% of children ages 0-15 were not restrained at all. In addition, only 46% of infants age 0-1, 59% of children aged 1-4, 28% of children aged 5-9 and 59% of children aged were in an age-appropriate restraint (Gitelman, Pesahov, and Carmel 2011). Observational surveys provide limited information on CRS misuse and installation issues; they are primarily able to provide information on levels of age-appropriate restraint use. Studies of CRS misuse indicate that 60-80% of the seats are incorrectly installed or misused (Bendjellal, 2008; Decina, 2005; Koppel, 2009). Studies have also shown that use of ISOFIX or LATCH to install a CRS significantly reduces misuse. For ISOFIX the estimates are a reduction to only 15% misuse and LATCH a reduction to 49% misuse (Bennett, 2011; Decina, 2007). The following research is the first in depth evaluation of CRS misuse patterns and installation issues in Israel. The study also includes a first time look at the awareness and use of CRS with ISOFIX and LATCH in Israel.

2 Objective To determine patterns of CRS misuse and installation problems in Israel To understand the knowledge and attitudes of parents regarding CRS To determine penetration of CRS with ISOFIX and LATCH and their use in Israel Methodology Analysis of data from CRS clinics Child safety seat clinics are conducted by certified technicians at Beterem headquarters in central Israel. Parents are invited to reserve an appointment and participate free of charge via a safety hotline. The parents are instructed to arrive with the CRS and manual and their vehicle and vehicle manual. A technician examines each seat on arrival and provides the parents with one on one instruction on how to install the seat correctly. The technician completes an intake form which includes various parameters: vehicle year and model; CRS model and regulations; anchorage systems available in the vehicle; CRS installation direction and method; child age, height and weight; and information on how child is secured in CRS (when child is in attendance). In total 13 clinics were held in and 251 CRS were examined. The sample included infant carriers (28%), toddler seats (55%), and booster seats (12%). Data from intake forms were keyed in for analysis. Knowledge, attitude and practice survey with parents An internet based KAP survey was conducted in September 2012 with 710 parents to children age 0-8. The survey used a stratified random sample with parent gender, child age group, and region of residence to control for representation of the Hebrew-speaking population in Israel. The response rate was 22% of the total sample; cooperation rate was 99% of the respondents 1. The internet panel, ipanel, the largest in Israel, has over 120,000 members and is capable of providing a representative sample of the Hebrew-speaking public in Israel within different population segments including parents of children. Quality control measures include out to potential survey participants who have not responded to a survey recently as well as checks of minimum time used to respond to the survey. Descriptive and inferential analysis was conducted using SPSS. Differences between groups that are presented are statistically significant at p=.0375 with a 95% confidence interval. Market survey of CRS models The market survey was designed to gather information about all of the CRS models sold in Israel. Two certified CRS technicians conducted the survey. An intake form with over 30 parameters was filled out for each of the CRS models identified including: model information, safety standards, seat type, installation options, weight and height minimum and maximum limits, width and height of seats, information about the labels and instructions and pricing. 1 Response rate based on AAPOR Response Rate 3 and Cooperation Rate 1; survey was ed to adults age 22-49; eligibility criteria were parents of children 0-8 and drivers; there were six break-off/ implicit refusals.

3 The information was gathered in flag stores of the four largest retailers of baby products and supplies as well as in three of the largest independent retailers. Additional information on pricing was collected on Israeli internet retail sites. The survey was conducted in August Results CRS installation and misuse The analysis of data from child safety seat clinics indicated that most of the CRS were installed in the rear seat; only 5% of the seats were installed in the front seat. In 25% of the vehicles the upper tether and lower ISOFIX/ LATCH anchorage points were available. An additional 28% had only lower anchorage points and 4% had only an upper anchorage point. Very few seats reviewed at the clinic were installed by parents using ISOFIX or LATCH; following the technicians assistance close to a quarter of the CRS were installed using ISOFIX or LATCH. In total misuse was identified for 80% of the CRS that were examined. Graph 1 presents the most common misuse issues. Graph 1. Common CRS misuse issues identified at clinics (N=216) Among the various misuse issues identified 70% of the seats had a critical misuse issue 1F2. Most of the CRS were installed with more than one misuse issue (62%) and a third had three misuse issues or more (35%). Many parents had difficulties related to installation: loose installation with a seat belt, incorrect use of a locking clip, and seat belt routed incorrectly. Knowledge and attitudes regarding CRS Overall most of the parents of children age 0-8 report using a CRS (96%), however 12% of parents to 4-8 year olds report that their children graduated to a seat belt. The reasons for graduation mentioned most often are that the child is too big for a booster seat or the seat 2 Misuse and critical misuse categories based on Decina, L. E., & Lococo, K. H. (2003). Misuse of child restraints. (Report No. DOT HS ). Washington, DC: National Highway Traffic Safety Administration.

4 belt fits. In addition, among those parents who report that they use a CRS; 13% indicate that they do not use a seat on every trip, in particular on short trips. Most parents in Israel report that they purchased the CRS or received a new CRS as a gift (88%). Graph 2 presents the parents primary consideration as well as additional considerations when purchasing a CRS. Graph 2 Considerations of parents when purchasing a CRS (N=557) 60% 50% Additional Consideration First Consideration 40% 33% 30% 34% 8% 20% 12% 10% 0% 23% 15% 24% 17% Comfortable for Price Safety standards Recommended Comfortable Design or "look" Easy to ins The first consideration among most of the parents in purchasing a CRS is the safety standard (24%), comfort for the child (23%), or a recommendation from family and friends (17%). Among parents with a lower household income the price was most commonly mentioned as the first consideration (28%). Overall the overriding concerns were comfort for the child (56%) and price (49%). Only 4% of parents indicated that ease of installation was a consideration in purchasing a CRS. Knowledge and attitudes regarding ISOFIX/LATCH Parents who use a CRS were asked whether they had heard of ISOFIX/LATCH in the vehicle and whether they could describe the purpose of this mechanism. Graph 3 details responses regarding parents knowledge about ISOFIX/LATCH. Graph 3 Knowledge about ISOFIX/LATCH (N=357) 12% 9% 7% 4% Installed on vehicle chassis Installation Safer Quicker More comfortable Only in some vehicles U.S. system Don't use a seatbelt Don't Know 2% 5% 4% 19% 70%

5 Most parents using a CRS are unfamiliar with ISOFIX/LATCH (70%). Among those parents who indicated that they are aware of the term the most common unaided description related to installation directly on the vehicle chassis provided by 19% of the parents. In addition, parents with lower income were less likely to indicate familiarity with ISOFIX/LATCH; among parents with higher income 39% were familiar with ISOFIX/LATCH, as opposed to 23% among median income, and only 14% among lower income parents. A follow up question used an explanation and images to aid awareness and was presented to the entire sample. Figure 1 are the images presented to the survey respondents. Graph 4 presents the parents aided awareness overall as well as awareness by the model year of the vehicle they own. Figure 1: Images of ISOFIX and LATCH included in KAP survey. ISOFIX LATCH Graph 4 Aided awareness of ISOFIX/LATCH overall and by vehicle model year (N=710) 70% Heard of LATCH Heard of ISOFIX Heard of both ISOFIX/LATCH 60% 50% 40% 30% 20% 10% 0% 14% 12% 12% 8% 22% 24% 15% 18% 13% 28% 10% 10% 9% 10% 1 All respondents

6 With aided awareness using a verbal explanation and images 44% of parents indicated that they are familiar with one or both of the installation methods. Familiarity with ISOFIX/ LATCH increases among parents with later model vehicles from 33% for owners of vehicles from model year to as high as 52% for owners of vehicles from Similarly familiarity is higher among parents with higher income than lower income and among parents with younger children than older children. Parents in Israel are more familiar with the ISOFIX system than the LATCH system (in particular parents of younger children). A quarter of the parents indicated that they own a CRS with ISOFIX or LATCH; 3 of the parents indicated that their CRS does not have such a system. However, 43% did not know if their CRS has ISOFIX or LATCH. Parents with ISOFIX or LATCH CRS were asked if they use the system for installation (see Graph 5). Graph 5 Use of ISOFIX or LATCH among parents with appropriate CRS (N=178) Among parents with an ISOFIX or LATCH CRS, 72% use the system to install the seat in their vehicle. Among those parents who do not use the system (25%); the most common reason is that their vehicle does not have ISOFIX (60%). A few parents mention difficulty using the system (14%, low N). For the most part parents using ISOFIX or LATCH are satisfied with the system citing that the system is safe, convenient, and stable (a tight installation). CRS models available in Israel The findings of the market survey point to over 180 models of CRS sold in Israeli retail stores. Approximately 70% of the CRS fall under the European standards and 30% fall under U.S. standards. Of the relevant seats only 30% have ISOFIX or LATCH installation capability. Overall CRS with ISOFIX or LATCH are more expensive than CRS models which only allow for seat belt installation. In addition to the information on the various CRS models a tip sheet was prepared for the Beterem safety hotline with recommendations on CRS models sold in the Israeli market that provide solutions for different situations (i.e. children with special needs, narrow vehicles, taller or heavier children, travel etc.). Conclusions Parents in Israel are aware of the need for a CRS; 96% of parents to children age 0-8 reported that they use a CRS. There is evidence that CRS are not used for every trip, in particular short trips or inner-city trips.

7 Early graduation is common as indicated previously in observational surveys for all age groups; in particular from booster seats to a seat belt. Similarly, in this study 12% of parents to children age 4-8 indicate that their child is too big for a booster seat, although the law requires booster seat use until age 8. Misuse of CRS in Israel is significant, misuse issues were identified for 80% of the CRS that were examined. Most of the CRS were installed with more than one misuse issue (62%) and a third had three misuse issues or more (35%). In Israel between 55% and 70% of the parents are unfamiliar with ISOFIX/ LATCH. Only a quarter of the parents report that their CRS has ISOFIX or LATCH and among those parents 72% use the system. Similarly, only 30% of the seats sold in Israel at this time have ISOFIX or LATCH capability. Familiarity with ISOFIX/ LATCH is higher for parents with newer vehicles, higher income, and younger children. Discussion While the use of CRS rose significantly over the last decade in Israel, recently CRS use has stagnated and is lower than in many European countries. Key issues for the Israeli public are the importance of CRS use on every trip, prevention of early graduation, and reduction of the high rates of CRS misuse. Similar to studies in Europe and the U.S.; misuse of CRS in Israel is often directly related to installation with a seat belt. Previous research indicates that ISOFIX and LATCH reduce misuse of CRS (Bennett, 2011; Decina, 2007), however in Israel awareness of the ISOFIX/ LATCH systems is low and simultaneously the market penetration of ISOFIX and LATCH seats is still limited. Low socioeconomic status has been found to be a predictor of child injury and low rates of child restraint use (Elliot et al. 2006). Higher costs of the advanced seats and older vehicles in use in the Israel may affect the use of ISOFIX and LATCH. The findings of this research are serving to develop a three-year multi-level intervention program to promote correct use of CRS and increased use of ISOFIX/ LATCH. Initial steps include education sessions with over 500 professionals including teachers, nurses, doctors, and social workers who work with children on a daily basis. A pamphlet and webpage for parents describing ISOFIX and LATCH were introduced in December Findings on CRS misuse were published in several popular newspapers. Study Limitations The data on misuse was limited to 251 CRS that were examined at child safety seat clinics. As parents who participate in these clinics do so voluntarily under their own initiative, the misuse data may not be representative of the general Israeli public. We assume that misuse in the general public may be even higher. An intercept study with a large and random sample of the population is necessary to present a more accurate picture of CRS misuse and use of ISOFIX/LATCH in Israel. In addition, the intake form for the child safety seat clinics was revised in November 2012 to allow for improvements in future analysis. Acknowledgements: This research is funded by the Britax Group.

8 Bibliography Bennett, M. and Bendjellal, F. (2011) Misuse: Recent Evaluations in Ireland Bendjellal, F. (2008) Misuse: Recent Evalua-tions in Ireland and France The need for a continuous and consistent parents education and development of technical solutions. Presented at: 6th Conference Protection of Children in Cars, Munich, December Decina, LE, Lococo, KH, (2005). Child restraint system use and misuse in six states. Accident Analysis and Prevention 37: Decina, LE, Lococo, KH, (2007). Observed LATCH use and misuse characteristics of child restraint systems in seven states. Journal of Safety Research 38: Durbin, D.R., Chen, I., Smith, R., Elliott, M.R., & Winston, F.K. (2005). Effects of Seating Position and Appropriate Restraint Use on the Risk of Injury to Children in Motor Vehicle Crashes. Pediatrics, 115(3), Elliott, M. R., Kallan, M. J., Durbin, D. R., & Winston, F. K. (2006). Effectiveness of child safety seats vs. seat belts in reducing risk for death in children in passenger vehicle crashes. Archives of Pediatrics & Adolescent Medicine, 160(6), European Transport Safety Council (ETSC), Reducing Child Deaths on European Roads, Road Safety Performance Index FLASH PIN 12. Brussels, Gitelman V, Pesahov F, & Carmel, R. The use of child safety restraints in passenger cars, 2010: Observation study findings. Haifa: The Ran Naor Road Safety Research Center and the Transportation Research Institute, Technion, 2011 (In Hebrew). Ivancovsky, M., Kislev, S., Child Injuries in Israel: 'Beterem' National Report Petach-Tikva: 'Beterem - Safe Kids Israel', Publication No. 1072, Apr (In Hebrew). Koppel, S, Charlton, JL (2009). Child restraint system misuse and/or inappropriate use in Australia. Traffic Injury Prevention 10: National Highway Traffic Safety Administration (NHTSA), Children: Traffic Safety Facts 2009, National Highway Traffic Safety Administration, DOT HS i Beterem The National Center for Children's Safety and Health, Israel, 18 Hasivim ST., P.O.B 7050 Petach-Tikva 49170, Israel Tel ,

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