Updated population-level estimates of child restraint practices among children aged 0-12 years in Australia, 10 years after introduction of age-appropriate restraint use legislation.

OBJECTIVE: Optimal child passenger protection requires use of a restraint designed for the age/size of the child (appropriate use) that is used in the way the manufacturer intended (correct use).This study aimed to determine child restraint practices approximately 10 years after introduction of legislation requiring correct use of age-appropriate restraints for all children aged up to 7 years. METHODS: A stratified cluster sample was constructed to collect observational data from children aged 0-12 years across the Greater Sydney region of New South Wales (NSW). Methods replicated those used in a similar 2008 study. Population weighted estimates for restraint practices were generated, and logistic regression used to examine associations between restraint type, and child age with correct use accounting for the complex sample. RESULTS: Almost all children were appropriately restrained (99.3%, 95% CI 98.4% to 100%). However, less than half were correctly restrained (no error=27.3%, 95% CI 10.8% to 43.8%, no serious error=43.8%, 95% CI 35.0% to 52.7%). For any error, the odds of error decreased by 39% per year of age (OR 0.61, 95% CI 0.46 to 0.81) and for serious error by 25% per year (OR 0.75, 95% CI 0.60 to 0.93). CONCLUSION: The findings demonstrate high levels of appropriate restraint use among children across metropolitan Sydney approximately 10 years after introduction of legislation requiring age-appropriate restraint use until age 7, however, errors in the way restraints remain common. IMPLICATIONS FOR PUBLIC HEALTH: Given the negative impact incorrect use has on crash protection, continuing high rates of incorrect use may reduce effectiveness of legislative change on injury reduction.

Differences in participant characteristics and observed child restraint use between population-based and restraint fitting service samples.

OBJECTIVE: To compare characteristics and restraint use between a population-based and fitting service sample of child restraint users. METHOD: Characteristics of the two samples were compared using chi-squared tests. Differences in errors in restraint use observed in the two samples were modeled using logistic regression. RESULTS: There were significant differences in child age (p < 0.001), and restraint types (p < 0.001) between the two samples, with more younger children in the fitting service sample. Controlling for differences in restraint type, the odds that adult participants were female were 61% less in the fitting service sample than in the population-based sample (OR 0.39, 95%CI 0.21-0.71). The odds that adult participants perceived a large risk associated with restraint misuse (OR 3.62, 95%CI 1.33-9.84), had a household income in the highest bracket (OR 3.89, 95%CI 1.20-12.62) and were living in areas of highest socioeconomic advantage (OR 2.72, 95%CI 1.22-6.06) were approximately three times higher in the fitting service sample. Overall, more participants had errors in restraint use in the population-based sample (p = 0.021). However, after controlling for restraint type, securing errors were three times more likely (OR 3.34, 95%CI 1.12-10.2), and serious installation errors were almost twice as likely (OR 1.91, 95% CI 1.09-3.39) in the fitting service sample. CONCLUSIONS: While less resource intensive, convenience and/or fitting service samples may be less representative than population-based samples. Given the need for efficiency, methods that combine randomized population-based invitations to participate in restraint fitting check day events across geographically representative areas may be useful for ongoing surveillance of child restraint use.

A Process Evaluation Protocol for Examining the Impact of Instructions for Correct Use of Child Car Seats Designed through a Consumer-Driven Process and Evaluated in a Field-Based Randomised Controlled Trial.

The incorrect use of child car seats is common, with significant negative effects on crash protection for child passengers. There is currently little evidence for effective, practical countermeasures for incorrect use. The provision of clear and comprehensible materials on correct use supplied with restraints at the point of sale could be highly cost-effective and achieve similar benefits to restraint-fitting services or hands-on training; however, routinely supplied instructions in their current form are frequently difficult to understand. We are conducting a randomised controlled trial of the consumer-driven redesign of instructional materials, consisting of an instruction sheet, swing tags and online training videos. This paper presents the protocol that will be used in an innovate process evaluation that will use the primary outcome of overall serious misuse assessed at six months, together with a survey and semi-structured interviews to determine fidelity, dose and outcomes for all intervention participants. The study will assess intervention delivery and external factors that may impact the effectiveness of the intervention, including experience, health literacy, confidence and attitudes. When it has been conducted, this process evaluation will provide enhanced understanding of the mechanisms through which the intervention works or not, aspects of the implementation process key to success of the intervention and insight into how external factors influence the success of the intervention.

Restraint Factors and Child Passenger Deaths in New South Wales, Australia.

Inappropriate or incorrect use of child restraints can influence crash injury outcome. This study examined the role of restraint factors in child passenger deaths and the effect of legislation requiring appropriate restraint systems up to 7 years old. Data for child (0-12 years) passenger deaths occurring in New South Wales (NSW) from 2007 to 2016 were collected by the child death review team including photographs, reports of in-depth crash investigation, witness reports and medical reports. Restraint use, type of restraint, appropriateness of the restraint for the age of the child and correctness of restraint use were examined. The primary contributor to death was determined in each case. Sixty-four child passengers died in NSW during the data period. Twenty-nine (29/64, 45%) were properly restrained. Thirteen children (13/64, 20%) were unrestrained. In 20 cases (20/64, 31%), children were using a restraint that was either inappropriate for their age (6) or not used correctly (14). Restraint factors were a primary contributor in 22 (22/64, 34%) child deaths. Compared to pre-legislation, appropriate restraint use was more common post-legislation (13/22. 59% vs. 30/42, 71%). However, incorrect use was also greater (3/22, 14% vs. 11/42, 26%). Interventions targeting increasing restraint use and reduction of common 'use' errors are needed to prevent further restraint factor-related deaths.

Can child restraint product information developed using consumer testing sustain correct use 6 months after child restraint purchase? Study protocol for a cluster randomised controlled trial.

BACKGROUND: With long-standing and widespread high rates of errors in child restraint use, there is a need to identify effective methods to address this problem. Information supplied with products at the point of sale may be a potentially efficient delivery point for such a countermeasure. The aim of this study is to establish whether product materials developed using a consumer-driven approach reduce errors in restraint use among purchasers of new child restraint systems. METHODS: A cluster randomised controlled trial (cRCT) will be conducted. Retail stores (n=22) in the greater Sydney area will be randomised into intervention sites (n=11) and control sites (n=11), stratified by geographical and socioeconomic indicators. Participants (n=836) will enter the study on purchase of a restraint. Outcome measures are errors in installation of the restraint as observed by a trained researcher during a 6-month follow-up home assessment, and adjustment checks made by the parent when the child is placed into the restraint (observed using naturalistic methods). Process evaluation measures will also be collected during the home visit. An intention-to-treat approach will be used for all analyses. Correct use and adjustment checks made by the parent will be compared between control and intervention groups using a logistic regression model. The number of installation errors between groups will be compared using Poisson regression. DISCUSSION: This cRCT will determine the effectiveness of targeted, consumer-driven information on actual error rates in use of restraints. More broadly, it may provide a best practice model for developing safety product information. TRIAL REGISTRATION NUMBER: ACTRN12617001252303p; Pre-results.

Does an on-road motorcycle coaching program reduce crashes in novice riders? A randomised control trial.

OBJECTIVES: Motorcycle riding is increasing globally and confers a high risk of crash-related injury and death. There is community demand for investment in rider training programs but no high-quality evidence about its effectiveness in preventing crashes. This randomised trial of an on-road rider coaching program aimed to determine its effectiveness in reducing crashes in novice motorcycle riders. METHODS: Between May 2010 and October 2012, 2399 newly-licensed provisional riders were recruited in Victoria, Australia and completed a telephone interview before randomisation to intervention or control groups. Riders in the intervention group were offered an on-road motorcycle rider coaching program which involved pre-program activities, 4h riding and facilitated discussion in small groups with a riding coach. Outcome measures were collected for all participants via telephone interviews at 3 and 12 months after program delivery (or equivalent for controls), and via linkage to police-recorded crash and offence data. The primary outcome was a composite measure of police-recorded and self-reported crashes; secondary outcomes included traffic offences, near crashes, riding exposure, and riding behaviours and motivations. RESULTS: Follow-up was 89% at 3 months and 88% at 12 months; 60% of the intervention group completed the program. Intention-to-treat analyses conducted in 2014 indicated no effect on crash risk at 3 months (adjusted OR 0.90, 95% CI: 0.65-1.27) or 12 months (adjusted OR 1.00, 95% CI: 0.78-1.29). Riders in the intervention group reported increased riding exposure, speeding behaviours and rider confidence. CONCLUSIONS: There was no evidence that this on-road motorcycle rider coaching program reduced the risk of crash, and we found an increase in crash-related risk factors.

Using police crash databases for injury prevention research - a comparison of opt-out and opt-in approaches to study recruitment.

OBJECTIVE: The study aimed to examine the difference in response rates between opt-out and opt-in participant recruitment in a population-based study of heavy-vehicle drivers involved in a police-attended crash. METHODS: Two approaches to subject recruitment were implemented in two different states over a 14-week period and response rates for the two approaches (opt-out versus opt-in recruitment) were compared. RESULTS: Based on the eligible and contactable drivers, the response rates were 54% for the opt-out group and 16% for the opt-in group. CONCLUSIONS AND IMPLICATIONS: The opt-in recruitment strategy (which was a consequence of one jurisdiction's interpretation of the national Privacy Act at the time) resulted in an insufficient and potentially biased sample for the purposes of conducting research into risk factors for heavy-vehicle crashes. Australia's national Privacy Act 1988 has had a long history of inconsistent practices by state and territory government departments and ethical review committees. These inconsistencies can have profound effects on the validity of research, as shown through the significantly different response rates we reported in this study. It is hoped that a more unified interpretation of the Privacy Act across the states and territories, as proposed under the soon-to-be-released Australian Privacy Principles(1) will reduce the recruitment challenges outlined in this study.

The use of self-report exposure measures among novice motorcyclists: appropriateness and best practice recommendations.

OBJECTIVES: While self-report methods to collect exposure information have large practical advantages in many research contexts, little research has specifically investigated the reliability and validity of motorcyclists' self-reported exposure. The present study aimed to examine the reliability and validity of different self-report exposure measures and to provide recommendations on best practice self-report riding exposure questions. METHODS: The reliability and validity of different self-report exposure measures were examined amongst novice motorcyclists through t-tests, Bland Altman plots, coefficients of variation, and correlations. RESULTS: The most valid and reliable data was provided when riding exposure was asked for the current average week rather than earlier and longer periods, and in units of time rather than distance or number of trips. The greater reliability of riding exposure found amongst commuting and rural riders compared to recreational and metropolitan riders respectively and at the second interview compared to the first suggests that factors such as riding purposes, geographical locations, and riding experience can contribute to measurement error. CONCLUSIONS: If self-reported odometer readings are used, questions on whether the respondents share their own bike or ride more than one bike, and a built-in process to ensure respondents report the exact odometer reading on their bike are recommended. It is recommended that self-report riding exposure questions ask about the hours of riding for the current average week, and data on riding purposes, locations, and experience are also collected.

The role of sleepiness, sleep disorders, and the work environment on heavy-vehicle crashes in 2 Australian states.

Heavy-vehicle driving involves a challenging work environment and a high crash rate. We investigated the associations of sleepiness, sleep disorders, and work environment (including truck characteristics) with the risk of crashing between 2008 and 2011 in the Australian states of New South Wales and Western Australia. We conducted a case-control study of 530 heavy-vehicle drivers who had recently crashed and 517 heavy-vehicle drivers who had not. Drivers' crash histories, truck details, driving schedules, payment rates, sleep patterns, and measures of health were collected. Subjects wore a nasal flow monitor for 1 night to assess for obstructive sleep apnea. Driving schedules that included the period between midnight and 5:59 am were associated with increased likelihood of crashing (odds ratio = 3.42, 95% confidence interval: 2.04, 5.74), as were having an empty load (odds ratio = 2.61, 95% confidence interval: 1.72, 3.97) and being a less experienced driver (odds ratio = 3.25, 95% confidence interval: 2.37, 4.46). Not taking regular breaks and the lack of vehicle safety devices were also associated with increased crash risk. Despite the high prevalence of obstructive sleep apnea, it was not associated with the risk of a heavy-vehicle nonfatal, nonsevere crash. Scheduling of driving to avoid midnight-to-dawn driving and the use of more frequent rest breaks are likely to reduce the risk of heavy-vehicle nonfatal, nonsevere crashes by 2-3 times.

Use of caffeinated substances and risk of crashes in long distance drivers of commercial vehicles: case-control study.

OBJECTIVE: To determine whether there is an association between use of substances that contain caffeine and the risk of crash in long distance commercial vehicle drivers. DESIGN: Case-control study. SETTING: New South Wales (NSW) and Western Australia (WA), Australia. PARTICIPANTS: 530 long distance drivers of commercial vehicles who were recently involved in a crash attended by police (cases) and 517 control drivers who had not had a crash while driving a commercial vehicle in the past 12 months. MAIN OUTCOME MEASURE: The likelihood of a crash associated with the use of substances containing caffeine after adjustment for factors including age, health disorders, sleep patterns, and symptoms of sleep disorders as well as exposures such as kilometres driven, hours slept, breaks taken, and night driving schedules. RESULTS: Forty three percent of drivers reported consuming substances containing caffeine, such as tea, coffee, caffeine tablets, or energy drinks for the express purpose of staying awake. Only 3% reported using illegal stimulants such as amphetamine ("speed"); 3,4 methylenedioxymethamphetamine (ecstasy); and cocaine. After adjustment for potential confounders, drivers who consumed caffeinated substances for this purpose had a 63% reduced likelihood of crashing (odds ratio 0.37, 95% confidence interval 0.27 to 0.50) compared with drivers who did not take caffeinated substances. CONCLUSIONS: Caffeinated substances are associated with a reduced risk of crashing for long distance commercial motor vehicle drivers. While comprehensive mandated strategies for fatigue management remain a priority, the use of caffeinated substances could be a useful adjunct strategy in the maintenance of alertness while driving.

Assessing sleepiness and sleep disorders in Australian long-distance commercial vehicle drivers: self-report versus an "at home" monitoring device.

STUDY OBJECTIVES: As obstructive sleep apnea (OSA) is associated with a higher risk of motor vehicle crashes, there is increasing regulatory interest in the identification of commercial motor vehicle (CMV) drivers with this condition. This study aimed to determine the relationship between subjective versus objective assessment of OSA in CMV drivers. DESIGN: Cross-sectional survey. SETTINGS: Heavy vehicle truck stops located across the road network of 2 large Australian states. PARTICIPANTS: A random sample of long distance commercial vehicle drivers (n = 517). INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Drivers were interviewed regarding their driving experience, personal health, shift schedules, payments, and various questions on sleep and tiredness in order to describe their sleep health across a range of variables. In addition, home recordings using a flow monitor were used during one night of sleep. Only 4.4% of drivers reported a previous diagnosis of sleep apnea, while our at home diagnostic test found a further 41% of long-distance heavy vehicle drivers likely to have sleep apnea. The multivariable apnea prediction index, based on self-report measures, showed poor agreement with the home-monitor detected sleep apnea (AUC 0.58, 95%CI = 0.49-0.62), and only 12% of drivers reported daytime sleepiness (Epworth Sleepiness Scale score > 10). Thirty-six percent of drivers were overweight and a further 50% obese; 49% of drivers were cigarette smokers. CONCLUSIONS: Sleep apnea remains a significant and unrecognized problem in CMV drivers, who we found to have multiple health risks. Objective testing for this sleep disorder needs to be considered, as symptom reports and self-identification appear insufficient to accurately identify those at risk.

The heavy vehicle study: a case-control study investigating risk factors for crash in long distance heavy vehicle drivers in Australia.

BACKGROUND: Heavy vehicle transportation continues to grow internationally; yet crash rates are high, and the risk of injury and death extends to all road users. The work environment for the heavy vehicle driver poses many challenges; conditions such as scheduling and payment are proposed risk factors for crash, yet the precise measure of these needs quantifying. Other risk factors such as sleep disorders including obstructive sleep apnoea have been shown to increase crash risk in motor vehicle drivers however the risk of heavy vehicle crash from this and related health conditions needs detailed investigation. METHODS AND DESIGN: The proposed case control study will recruit 1034 long distance heavy vehicle drivers: 517 who have crashed and 517 who have not. All participants will be interviewed at length, regarding their driving and crash history, typical workloads, scheduling and payment, trip history over several days, sleep patterns, health, and substance use. All participants will have administered a nasal flow monitor for the detection of obstructive sleep apnoea. DISCUSSION: Significant attention has been paid to the enforcement of legislation aiming to deter problems such as excess loading, speeding and substance use; however, there is inconclusive evidence as to the direction and strength of associations of many other postulated risk factors for heavy vehicle crashes. The influence of factors such as remuneration and scheduling on crash risk is unclear; so too the association between sleep apnoea and the risk of heavy vehicle driver crash. Contributory factors such as sleep quality and quantity, body mass and health status will be investigated. Quantifying the measure of effect of these factors on the heavy vehicle driver will inform policy development that aims toward safer driving practices and reduction in heavy vehicle crash; protecting the lives of many on the road network.