Kate Hunter

Buckle up safely: a cluster randomised trial to evaluate the effectiveness of a pre-school based program to increase appropriate use of child restraints

BackgroundRoad traffic crashes for car occupants are a leading cause of death and serious injury in children from high and middle income countries globally. Correct use of appropriate child restraints can significantly reduce death and serious injury but there is a need for well powered trials to examine effectiveness of programs to increase optimal child restraint practices. The aim of this trial is to examine the effectiveness of a comprehensive intervention to increase the use of appropriate child restraints, and decrease incorrect use of child restraints in pre-school aged children traveling in cars.Methods and DesignA cluster randomised controlled trial will be conducted, involving 28 pre-school or childcare centres in low income areas of Sydney, Australia, over one calendar year. The intervention is an educational program involving an in-service for centre staff, distribution of educational materials to parents, a parent workshop demonstrating restraint use, subsidised restraints for parents in need, and vouchers for a free restraint checking service. Blinded assessors will observe restraint use at all centres at the end of the calendar year. Data will be analysed on an intention-to-treat basis; the primary analysis will compare the proportion of each of the two outcome measures (use of appropriate restraints, and incorrect use of restraints) at each centre between intervention and control groups. Detailed process evaluation will be conducted, including examination of implementation and utilisation of various elements of the program by both centres and families.DiscussionThis assessor blinded cluster randomised trial is powered to provide credible evidence about the efficacy of an education and distribution program in a pre-school setting to increase appropriate use, and decrease incorrect use of child restraints.Trial registrationAustralian New Zealand Clinical Trials Registry ACTRN12609000612213.

Child restraint use in low socio-economic areas of urban Sydney during transition to new legislation

Child restraints protect a young child against injury in crashes but best practice child restraint use is low in Australia, particularly among lower socio-economic groups. We investigated factors associated with restraint use to inform the development of education and distribution programmes to support new Australian legislation on child passengers among families in low socio-economic areas of metropolitan Sydney. We interviewed a parent or carer of 1160 children aged 2-5 years enrolled at one of 28 early childhood centres in low socio-economic areas of urban Sydney. Appropriate child restraint use was defined as a forward facing child restraint (FFCR) for 2-3 year olds and a FFCR or booster seat for children aged 4 years or more. Predictors of self-reported appropriate use were explored using logistic regression. Analysis was conducted on one child from each family in the target age range (2-5 years): 586 (51%) were male and the mean age was 3.5 (Standard Deviation 0.8) years. There were 432 (45%) families with annual income below

Evaluation of an Education, Restraint Distribution, and Fitting Program to Promote Correct Use of Age-Appropriate Child Restraints for Children Aged 3 to 5 Years: A Cluster Randomized Trial

60,000, 248 (22%) spoke a language other than English at home and 360 (33%) had 3 or more children. Fifty-four percent of carers indicated that their 2-3 year old children travelled in a FFCR. Inappropriate use among children in this age group was more likely when the carer was <36 years (odds ratio (OR) 1.62, 95% confidence interval (CI) 1.08-2.45), in families with ≥3 children (OR 1.64, 95% CI 1.10-2.44) and when the carer believed that a booster seat was just as safe as a FFCR (OR 2.98, 2.05-4.32). Eight-eight percent of carers of 4-5 year olds reported use of a booster seat or FFCR. Non-use was associated with low household income (OR 3.10, 95% CI 1.67-5.75), in families with ≥3 children (OR 2.03, 95% CI 1.09-3.76) and families where a language other than English is spoken at home (OR 2.39, 95% CI 1.10-5.21). Non-English speaking families had less awareness of the new law and poorer knowledge of safety benefits of child restraints. They also had lower household incomes and more concerns about cost of child restraints and booster seats. These findings can inform development of interventions to promote best practice child restraint use, which will reach non-English speaking families in this region. They also confirm the importance of economic and logistic barriers to best practice child restraint use.

Increase in best practice child car restraint use for children aged 2-5 years in low socioeconomic areas after introduction of mandatory child restraint laws

OBJECTIVES We evaluated an education, distribution, and fitting program for increasing age-appropriate and correct child restraint use. METHODS We performed a cluster randomized trial involving 28 early childhood education centers in low socioeconomic status areas in Sydney, Australia. The main outcome was optimal restraint use defined as age-appropriate restraints, installed into the vehicle correctly and used correctly. RESULTS One service withdrew after randomization, so data are presented for 689 child passengers, aged 3 to 5 years, from 27 centers. More children attending intervention centers were optimally restrained (43% vs 31%; P = .01; allowing for clustering). More 3-year-olds were using forward-facing seats rather than booster seats, more 4- to 5-year-olds were using booster seats instead of seat belts alone, and there were fewer errors in use at intervention centers. Among non-English-speaking families, more children attending intervention centers were optimally restrained (43% vs 17%; P = .002; allowing for clustering). CONCLUSIONS The program increased use of age-appropriate restraints and correct use of restraints, which translates to improved crash injury protection. Multifaceted education, seat distribution, and fitting enhanced legislation effects, and the effect size was larger in non-English-speaking families.

Buckle up safely (Shoalhaven): a process and impact evaluation of a pragmatic, multifaceted preschool-based pilot program to increase correct use of age-appropriate child restraints

Objectives : To examine changes in child car restraint practices in low socioeconomic areas following the introduction of mandatory child car restraint legislation in New South Wales (NSW), Australia.

Driver licensing: descriptive epidemiology of a social determinant of Aboriginal and Torres Strait Islander health

Objective: To conduct a process and impact evaluation of a multifaceted education-based pilot program targeting correct use of age-appropriate restraints in a regional setting with a high proportion of Aboriginal and Torres Strait Islander families. Methods: The program was delivered in 2010 in 3 early learning centers where 31 percent of the children were of Aboriginal and Torres Strait Islander descent. Each component of the program was assessed for message consistency and uptake. To measure program effectiveness, participating children were matched 1:1 by age, language spoken at home, and annual household income with 71 children from the control arm of a contemporaneous trial. The outcome measure in the control and program centers (a 4-category ordinal scale of restraint use) was compared using ordinal logistic regression accounting for age of the parent. Results: Process evaluation found that though program components were delivered with a consistency of message, uptake was affected by turnover of all staff at one center and by parents experiencing difficulty in paying for subsidized restraints at each of the centers. Impact evaluation found that children from the centers receiving the program had nearly twice the odds of being in a better restraint category than children matched from the control group (adjusted odds ratio [ORadj] = 2.06, 95% confidence interval [CI], 1.09–3.90). Conclusions: This was a pragmatic study reflecting the real-life issues of implementing a program in preschools where 57 percent of families had a low income and turnover of staff was high. Despite these issues, impact evaluation showed that the integrated educational program showed promise in increasing correct use of age-appropriate restraints. The findings from this pilot study support the use of an integrated educational program that includes access to subsidized restraints to promote best practice child restraint use among communities that include a high proportion of Aboriginal and Torres Strait Islander families in New South Wales. Future trials in similar settings should consider offering more support in centers with high turnover of staff and offering alternative methods of payment when families experience financial difficulties in purchasing the subsidized restraints. If proven in larger trials, this approach could reduce death and injuries in child passengers in this vulnerable group.

Understanding burn injuries in Aboriginal and Torres Strait Islander children: Protocol for a prospective cohort study

Objective: Education, employment and equitable access to services are commonly accepted as important underlying social determinants of health. For most Australians, access to health, education and other services is facilitated by private transport and a driver licence. This study aimed to examine licensing rates and predictors of licensing in a sample of Aboriginal and Torres Strait Islander people, as these have previously been poorly described.

Program Fidelity Measures Associated With an Effective Child Restraint Program: Buckle-Up Safely

Introduction Although Aboriginal and Torres Strait Islander children in Australia have higher risk of burns compared with non-Aboriginal children, their access to burn care, particularly postdischarge care, is poorly understood, including the impact of care on functional outcomes. The objective of this study is to describe the burden of burns, access to care and functional outcomes in Aboriginal and Torres Strait Islander children in Australia, and develop appropriate models of care. Methods and analysis All Aboriginal and Torres Strait Islander children aged under 16 years of age (and their families) presenting with a burn to a tertiary paediatric burn unit in 4 Australian States (New South Wales (NSW), Queensland, Northern Territory (NT), South Australia (SA)) will be invited to participate. Participants and carers will complete a baseline questionnaire; follow-ups will be completed at 3, 6, 12 and 24 months. Data collected will include sociodemographic information; out of pocket costs; functional outcome; and measures of pain, itch and scarring. Health-related quality of life will be measured using the PedsQL, and impact of injury using the family impact scale. Clinical data and treatment will also be recorded. Around 225 participants will be recruited allowing complete data on around 130 children. Qualitative data collected by in-depth interviews with families, healthcare providers and policymakers will explore the impact of burn injury and outcomes on family life, needs of patients and barriers to healthcare; interviews with families will be conducted by experienced Aboriginal research staff using Indigenous methodologies. Health systems mapping will describe the provision of care. Ethics and dissemination The study has been approved by ethics committees in NSW, SA, NT and Queensland. Study results will be distributed to community members by study newsletters, meetings and via the website; to policymakers and clinicians via policy fora, presentations and publication in peer-reviewed journals.

Implementation of a driver licensing support program in three Aboriginal communities: a brief report from a pilot program.

OBJECTIVES We sought to identify the program fidelity factors associated with successful implementation of the Buckle-Up Safely program, targeting correct use of age-appropriate child car restraints. METHODS In 2010, we conducted a cluster randomized controlled trial of 830 families with children attending preschools and long day care centers in South West Sydney, New South Wales, Australia. Families received the Buckle-Up Safely program in the intervention arm of the study (13 services). Independent observers assessed the type of restraint and whether it was used correctly. RESULTS This detailed process evaluation showed that the multifaceted program was implemented with high fidelity. Program protocols were adhered to and messaging was consistently delivered. Results from multilevel and logistic regression analyses show that age-appropriate restraint use was associated with attendance at a parent information session hosted at the center (adjusted odd ratio [AOR]=3.66; 95% confidence interval [CI]=1.61, 8.29) and adversely affected by the child being aged 2 to 3 years (AOR=0.14; 95% CI=0.07, 0.30) or being from a family with more than 2 children (AOR=0.34; 95% CI=0.17, 0.67). CONCLUSIONS Findings highlight the importance of parents receiving hands-on education regarding the proper use of age-appropriate child restraints.

Challenges to driver licensing participation for Aboriginal people in Australia: a systematic review of the literature

Issue addressed: Aboriginal people face significant barriers to accessing the driver licensing system in New South Wales (NSW). Low rates of licence participation contribute to transport disadvantage and impede access to employment, education and essential health services. The Driving Change program has been piloted in three communities to increase licensing rates for young Aboriginal people. This brief report reviews implementation to determine whether Driving Change is being delivered as intended to the target population.Methods: Descriptive analysis of routinely collected program data collected between April 2013 and October 2014 to monitor client demographics (n = 194) and program-specific outcomes.Results: The target population is being reached with the majority of clients aged 16-24 years (76%) and being unemployed (53%). Licensing outcomes are being achieved at all pilot sites (learner licence 19%; provisional or unrestricted licence 16%). There is variation in program delivery across the three pilot sites demonstrating the intended flexibility of the program.Conclusions: Driving Change is delivering all aspects of the program as intended at the three pilot sites. The program is reaching the target population and providing a sufficiently flexible program that responds to community and client identified need.So what?: Reviewing implementation of community pilot programs is critical to ensure that the intervention is being delivered as intended to the target population. This brief report indicates that Driving Change is assisting young Aboriginal people to access licensing services in NSW. This review of program implementation will assist the subsequent expansion of the program to a further nine communities in NSW.