A school-based program to increase seatbelt use

Journal of Family Practice, Nov, 1989 by Robert Morrow

The internal combustion engine has transformed the Western way of life-and death. Children are injured and killed by automobile accidents at rates that compare with the great plagues of the past. Over the last quarter century, accidents have been the leading cause of death for children between the ages of I and 14 years of age, and automobile accidents produce roughly one half the mortality; of this number, one half are passengers, at a rate greater than 600 yearly.1.1 Adults also die and are maimed in large numbers as passengers of automobiles.

Ways do exist to reduce this epidemic. Safer vehicles, safer roads, and safer drivers all contribute to a safer environment. Seatbelt use, however, has an immediate role in reducing the death and injury rate, and seatbelts are available in most vehicles. The benefits of proper restraints for drivers and passengers are clear from experimental and epidemiological data.(1-6)

The data are remarkable; in 1983, nearly 30,000 occupants of automobiles died on US highways. Only 484 (2%) were reportedly wearing seatbelts.(1) Properly used restraints could prevent at least 60% of serious injuries to older children, teenagers, and adults;(5) virtually all serious injuries to infants and younger children would also be prevented.6

Use rates are quite low, especially for young children. Legislation in all 50 states mandates proper use of safety restraints for children aged 5 years and younger. A majority of states have laws for older occupants.(5) In New York State a law raised seatbelt use from 20% to 76%, but after I year, use dropped to 45%.8 A 1981 survey found only 17% of children aged over 3 years were restrained by report,(1) with such reporting over-estimating real use.9 An arresting finding from Quebec showed good increases after a law was passed, with adult rates increasing from 14.7% to 55.5%, but children aged 5 to I I went from 3.7% to only 23.0%."

In general, researchers have paid little attention to the early school age group, though this age is particularly vulnerable both to injury and to formative ideas. These children are out of car safety seats, in which they are placed by someone older, and into seatbelts, which they put on themselves. In that sense, they can "speak for themselves," making a choice that was not available to them when they were younger, and, statistically, many of these children make the wrong choice and suffer the consequences. At this age school teaches them to be social beings by defining normative social behavior outside the family setting (such as being quiet in class and obeying other rules). This study addresses both the physical vulnerability and intellectual receptiveness of this young age group. Interesting work has been done by Bowman et al(11) in Australia on preschoolers aged 3 to 5 years. They point out that, whereas legislation has been spectacularly successful in increasing use by adults (80%) and infants 6 months to 4 years 80.9%), children aged 4 to 7 years had a rate of 46.4%. They attribute this low rate both to a child's testing of parental authority and the parental wish to avoid conflict. They then offered two interventions: a coercive one aimed at parents (threats of fines), and an educational one aimed at the children only. Coercion did not effect any change; the educational group seatbelt use rate rose from 60.6% to 75.0%. Drivers showed scanty changes. Chang and colleagues (12) found a similar but smaller benefit in California for an educational program aimed at both children and their parents. Use of a safety seat or seatbelt rose in this group of children from 21.9% to 44.3%. Other related studies demonstrate the positive effects physicians can have on safety behavior in infants,(13) but apparently physicians are effective at the reported rate of 15 percent.(14) Community-based interventions seem to have small effects.(15-17) The study reported here evaluates ways in which these statistics can be improved. A curricular intervention was designed and implemented, and seatbelt use rates were measured before and after the intervention. The intervention was focused entirely on the children, but driver use rates were also measured.

This study involved one large school, with a target month of intervention. This participatory, educational intervention was aimed exclusively at the children, with no sessions or materials for the parents. Placing car safety at the center of the school's curriculum was the key to the intervention. Every month has its own icon, or symbol; for example, November has a turkey, October a carved pumpkin, February a heart. May was "Buckle-up" month. METHODS Sample A magnet school in Yonkers, New York, was selected because it was centrally located, attracting students from the entire city. Children arrived by private car (the study group) and by bus (not counted). Pupils reflected a diverse racial and socioeconomic group. This school is committed to a "gifted and talented" program, with all students passing an entrance examination, and it spans prekindergarten through second grade (ages 4 through 8 years). The Yonkers school was chosen because it requires transport of the children. Traditionally, this age group attends neighborhood schools and arrives on foot. The principal investigator was also the chair of the Health and Safety Committee of the Parent Teacher Association and thus able to facilitate the study as a volunteer. At the time of the study the school had a population of 422 children evenly divided among the four grades. Preintervention counts in April 1986 included 125 children and 132 drivers (a few children were missed by the observers owing to the newness of counting children). After intervention, 147 children and 150 adults were counted. At the 1 month follow-up, 107 children and 107 adults were counted.