May 2007

Document Type


Degree Name



Dept. of Public Health and Preventive Medicine


Oregon Health & Science University


Objective: To determine child, driver, and vehicle characteristics associated with proper, incorrect, and non-restraint use among Northwest American Indian children traveling in motor vehicles. Background: Injuries are the leading cause of death for American Indian and Alaska Native (AI/AN) children and adults age 1-44. AI/AN children have the highest motor vehicle injury mortality rate of any race or ethnic group in the United States. AI/AN children are 3.8 times more likely to die from a motor vehicle injury than all races children. There is overwhelming evidence that child safety seats are effective at reducing injury when used properly, however, restraint use among AI/AN children in the Northwest has not been well established. Methods: This project utilized data from the 2003 Northwest Tribal Child Safety Seat Project, a cross-sectional observational study conducted in six Northwest tribes. Drivers of vehicles with child passengers were observed for driver and child restraint use, and drivers were asked child's age, weight, vehicle characteristics, and their opinions about child safety seat use. Children in the dataset were classified as being properly, incorrectly, or unrestrained based on reported age and weight and according to recommendations from the American Academy of Pediatrics and the National Highway Traffic Safety Administration (NHTSA). Data were analyzed using three binary logistic regression models comparing each child restraint category: properly restrained vs unrestrained, incorrectly restrained vs unrestrained, and properly restrained vs incorrectly restrained. Regression models were adjusted for clustering of children in a vehicle using a generalized estimating equation (GEE) method. Results: Of 775 children age 1-8 years, 29 percent were properly restrained, 30 percent were incorrectly restrained, and 41 percent were completely unrestrained in the vehicle. The strongest associations with proper child restraint use, rather than no restraint use, were seat eligibility (Odds Ratio [OR] for infant seat vs booster seat: 25.1; OR for child seat vs booster seat: 8. 7), driver seat belt use (OR: 6.5), and driver relationship to the child (OR for parents vs non-parents: 3.9). Being subject to a state seat belt law was associated with both proper (OR: 4.4) and incorrect restraint use (OR: 6.6), rather than no restraint use, compared to children riding in areas with no law. Being subject to a tribal seat belt law was also associated with incorrect restraint use (OR: 2.4), rather than no restraint use, compared to children riding in areas with no law. The three factors that were differently associated with proper and incorrect restraint use were the child's seat eligibility (OR for infant seat vs booster seat:15.7; OR for child seat vs booster seat: 7.5), seating position (OR for rear-outboard seated vs front seated: 1.9), and whether or not the child was riding with his or her own parent (OR for parents vs non-parents:2.9). Conclusions: AI/AN children are at risk for incorrect and non-use of motor vehicle restraints. Understanding barriers and facilitators to the use of child passenger restraint systems in tribal communities can guide prevention efforts for American Indian communities across the United States. Such interventions might include strategies to get all occupants (adults and children) to use proper restraints; stressing importance of regular use, even for short trips; increase availability of proper seats for all vehicles that children ride in regularly; include training on proper use, not only for parents, but all regular caregivers.




School of Medicine



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