Article—Systematic Evidence Review
Selvi B. Williams, MD, MPHa; Evelyn P. Whitlock, MD, MPHa; Elizabeth A. Edgerton, MD, MPHb; Paula R. Smith, RN, BSNa; and Tracy L. Beil, MSa
The authors of this article are responsible for its contents,
including any clinical or treatment recommendations. No statement in
this article should be construed as an official position of the Agency for
Healthcare Research and Quality or the U.S. Department of Health and
Human Services.
This article was first published in the Annals of Internal Medicine. Select for copyright and source information.
Contents
Abstract
Introduction
Methods
Results
Discussion
References
Notes
Abstract
Background: Motor vehicle–related injuries are the leading cause of
death among children, adolescents, and young adults.
Purpose: To systematically review evidence of the effectiveness of
counseling people of any age in primary care settings about occupant
restraints or alcohol-related driving to prevent injuries.
Data Sources: MEDLINE®, Cochrane Central Register of Controlled
Trials, Cochrane Database of Systematic Reviews, PsycINFO,
CINAHL, and Traffic Research Information Service; published systematic
evidence reviews; experts; and bibliographies of selected
trials.
Study Selection: Randomized, controlled trials (RCTs); controlled
clinical trials (CCTs); or comparative observational research studies
that evaluated behavioral counseling interventions feasible to conduct
in primary care or referral from primary care.
Data Extraction: Investigators abstracted data on study design,
setting, patients, interventions, outcomes, and quality-related study
details.
Data Synthesis: Trials report that counseling to increase the use of
child safety seats leads to increased short-term restraint use (7
CCTs, 6 RCTs). Interventions that included a demonstration of
correct use or distribution of a free or reduced-cost child safety seat
reported larger effects. Few trials described the effect of counseling
children 4 to 8 years of age to use booster seats (1 RCT); counseling
older children, adolescents, or adults to use seat belts (1 CCT,
2 RCTs); or counseling unselected primary care patients to reduce
alcohol-related driving behaviors (no trials).
Limitations: Most of the relevant trials were published before the
widespread enactment of child safety seat legislation and had
methodological flaws.
Conclusions: The incremental effect of primary care counseling to
increase the correct use of child safety seats in the current regulatory
environment is not established. The effectiveness of primary
care counseling to reduce alcohol-related driving has not been
tested. Studies are needed.
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Introduction
Motor vehicle–related injuries are the leading cause of
death among individuals between 3 and 33 years of
age in the United States1 and are a large source of morbidity for the nearly 3 million people who sustain nonfatal
injuries annually.2 Increasing the correct use of occupant restraint devices and decreasing alcohol-related driving
(that is, driving while under the influence of alcohol or
riding with drivers who are under the influence of alcohol)
are among the most important strategies to effectively reduce
motor vehicle–related fatalities.3-8 Overall, occupant
restraint use has been increasing and is considered a
public health success.9 All 50 states currently have laws
requiring child safety seats for infants and children, and 49
states and the District of Columbia have adult seat belt
laws.10 Although belt-positioning booster seats reduce
the risk for injury by nearly 60% for children 4 to 7 years
of age11 compared with seat belts, 22 states do not have
any laws pertaining to booster seats. All 50 states, the District
of Columbia, and Puerto Rico have laws that make it
illegal to drive with a blood alcohol concentration of 0.08
g/dL or higher9, and rates of alcohol involvement among
fatal crashes have decreased during the past 2 decades.12
Despite widespread regulation and overall increases in
safer motor vehicle–related behaviors, recent crash data
show that more than 50% of fatalities were among unrestrained
occupants and nearly 40% involved alcohol.2
Primary care providers and their staff have many opportunities
to intervene with patients about these health behaviors
already known to reduce the risk for motor vehicle
occupant injuries (MVOIs). Children and adolescents
younger than 15 years of age average more than 2 visits per
year to office-based physicians, and older adolescents and
adults average 2 to 8 visits per year.13 Additional public health strategies, such as closing gaps in current laws14 and implementing evidence- and population-based
approaches8,15,16, will be important to make further
improvements in motor vehicle safety behaviors. These strategies could include components delivered by
primary health care providers or their staff.
Our objective was to systematically assess the evidence
on the effectiveness of primary care counseling among people
of all ages to increase the correct use of age- and
weight-appropriate occupant restraint devices and reduce
alcohol-related driving. The Oregon Evidence-based Practice
Center (EPC) conducted the review to assist the U.S.
Preventive Services Task Force (USPSTF) in updating its
1996 recommendation.17 The full evidence report is
available at www.preventiveservices.ahrq.gov. This article summarizes the review's findings.
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Methods
Key Questions
In conjunction with members of USPSTF, we developed
an analytic framework (Appendix Figure 1) and 4 key questions to guide our evidence review.
Key question 1: Do primary care behavioral counseling
interventions for children, adolescents, and adults to increase
the correct use of age- and weight-appropriate restraints or
reduce driving/riding with drivers under the influence of alcohol
reduce morbidity and/or mortality from motor vehicle
occupant injuries?
Key question 2: Do primary care behavioral counseling
interventions for children, adolescents, and adults lead to increased
correct use of age- and weight-appropriate restraints?
Key question 3: Do primary care behavioral counseling
interventions for children, adolescents, and adults reduce driving/riding with drivers under the influence of alcohol?
Key question 4: What are the adverse effects of counseling
children, adolescents, and adults to correctly use age- and
weight-appropriate restraints and reduce driving/riding with
drivers under the influence of alcohol?
Key question 1 addressed the direct effect of counseling
interventions on actual health risk reductions, whereas
key questions 2 and 3 addressed effects on intermediate
behavioral outcomes known to lead to health risk reduction.
This report did not examine the evidence for the
efficacy of health risk reduction for the targeted MVOI-related
safety behaviors, because the USPSTF found strong
evidence for those relationships in 1996.17 Correct use
is defined by age, weight, and location as recommended by
traffic safety organizations.18 Appendix Table 1 describes recommended occupant restraint devices for children younger than 9 years of age.
Children younger than 13 years of age should ride in the
rear of the vehicle. Safety belts with straps across both the
lap and shoulder are recommended for children who have
outgrown booster seats, as well as for adolescents and
adults.
Data Sources
We considered all studies that were included in the
1996 USPSTF recommendation, and we conducted 5 additional
literature searches that were limited to English-language
studies. For the key questions pertaining to occupant
restraint use (1 and 2), we searched for relevant
studies in MEDLINE®, Cochrane Central Register of Controlled
Trials, Cochrane Database of Systematic Reviews,
PsycINFO, CINAHL, and Traffic Research Information
Service (TRIS) published from 1992 to July 2005. We also
searched the bibliographies of 4 systematic evidence reviews
that addressed the effectiveness of counseling for occupant
restraints in pediatric populations.16,19-21 For
the key questions addressing counseling about driving
while under the influence of alcohol (1 and 3), we considered
trials that were included in 3 recent systematic evidence
reviews22-24 and searched MEDLINE®, Cochrane
Central Register of Controlled Trials, Cochrane Database
of Systematic Reviews, PsycINFO, CINAHL, and TRIS
for studies published from 2002 to September 2005 to
update the searches conducted for those reports.
In 1996, the USPSTF recommendation did not specifically
address the effectiveness of counseling patients
about riding with someone who was under the influence of
alcohol (key question 3) or the harms of counseling (key
question 4). To cover these 2 areas, we searched MEDLINE®,
Cochrane Central Register of Controlled Trials,
Cochrane Database of Systematic Reviews, PsycINFO, CINAHL,
and TRIS for studies published from 1966 to July
2005 and MEDLINE and TRIS for studies published
from 1966 to September 2005, respectively. Although no
key questions were related to cost, we searched the National
Health Service Economic Evaluation Database for
data published from the database's inception through July
2005. Literature searches are described in detail in Appendix
Table 2 and were supplemented with outside source material from experts in the
field.
Study Selection
Two authors reviewed each abstract for potential inclusion
by using the inclusion and exclusion criteria described
in Appendix Table 3. We conducted 5 searches to cover the separate focus
of each key question, and we reviewed all abstracts for
potential inclusion for any of the key questions. For all key
questions, we included English-language reports of randomized,
controlled trials (RCTs) or nonrandomized, controlled
clinical trials (CCTs) and comparative observational
studies that included patients of any age and were conducted
in the United States or other similarly developed
countries. Any intervention that included behavioral counseling
as 1 of its components was considered. Studies were
required to report 1 of the behavioral or health outcomes
specified in our key questions and analytic framework or
cost-effectiveness outcomes. We excluded studies rated as
having poor quality on the basis of the criteria described in
the following section.
To be within the scope of the USPSTF, interventions needed to be feasible for, or conducted in, a primary care setting or be available for primary care referral. Criteria for
deciding whether the intervention was feasible for a primary
care setting were developed previously by members of
the Oregon EPC and the USPSTF. These criteria included
4 domains: 1) how the participant was identified, 2) who
delivered the intervention, 3) how the intervention was
delivered, and 4) where the intervention was delivered. Appendix
Table 4 contains a more detailed description of these domains. For an intervention
to be feasible for primary care referral, we required
that it be conducted in a health care setting or be widely
available in the community at a national level (such as a car
seat–fitting station within a hospital). We excluded studies
that enrolled selected populations (for example, injured or
intoxicated patients recruited from an emergency department)
that were not representative of patients normally
seen in primary care.
Our review did not include programs that counseled
risky or harmful alcohol users to reduce alcohol consumption,
which was reviewed previously for the USPSTF.22
Rather, we required that alcohol-related counseling interventions
target general primary care patient populations of
any age and specifically advise patients to reduce drinking
and driving (not just reduce overall use of alcohol).
Data Extraction and Quality Assessment
Using the USPSTF's study design–specific criteria25,26, 2 authors rated the quality of all included studies and
those excluded because of quality issues. For randomized,
controlled trials, criteria included 1) the initial assembly of
comparable groups (based on adequate randomization, including
first concealment and whether potential confounders
were distributed equally among groups); 2) maintenance
of comparable groups (including attrition, crossover,
adherence, and contamination); 3) important differential
loss to follow-up or overall high loss to follow-up; 4) equal,
reliable, and valid measurements (includes masking of outcome
assessment); 5) clear definition of interventions; 6) all
important outcomes considered; and 7) an intention-to-treat
analysis. For nonrandomized, controlled trials or cohort
studies, the initial assembly of comparable groups was
judged on the basis of consideration of potential confounders,
with either restriction or measurement for adjustment.
In the analyses of results of nonrandomized studies, adjustment
for confounders was a quality criterion. The USPSTF
Methods Work Group has defined a 3-category rating
of "good," "fair," and "poor" on the basis of these criteria.
In general, a good-quality study meets all criteria well. A
fair-quality study does not meet, or is not clear that it
meets, at least 1 criterion but has no known important
limitation that could invalidate its results. A poor-quality
study has important limitations. The specifications are not
meant to be rigid rules. Rather, they are intended to be
general guidelines. Individual exceptions, when explicitly
explained and justified, can be made. Appendix Table 5 describes the USPSTF quality
criteria in detail.
For all included studies, 1 primary reviewer abstracted
relevant information into standardized evidence tables and
a second author checked the abstracted data. If the investigators
disagreed on study content or quality, a third investigator
reviewed the study and the final quality rating
was based on agreement between 2 of the 3 reviewers.
Studies receiving a final quality rating of "poor" (n = 23)
were excluded. Major quality problems in studies rated as
poor included noncomparable groups at baseline, attrition
greater than 40 percent, and nonblinded outcome assessment by
the interventionists or nonstandardized outcome assessment.
Because many trials had several methodological
problems but were not clearly biased, we rated some included
studies as "fair to poor quality." In general, fair-quality
studies reported or matched on some important
baseline characteristics, measured outcomes by observation,
specified correct use, and had lower attrition. Fair- to poor-quality
studies often did not report baseline characteristics,
used self-reported outcomes, did not specify correct use,
and had higher attrition rates.
Data Synthesis and Analysis
We could not conduct quantitative synthesis for any
key question because of heterogeneity of intervention
methods, populations addressed, and settings. Instead, we
qualitatively synthesized our results within categories, focusing
first on the age of the population for which MVOI
safety behaviors were addressed and second on the setting
in which the population was identified and in which the
intervention was delivered. Detailed qualitative summaries
are reported in the full evidence report and are summarized
in this review. For interventions targeting child safety seat
use, results were also stratified by whether the program
included a demonstration of correct child safety seat use or
increased access through a free or discounted distribution
program. We calculated absolute differences with 95 percent CIs
for use of restraints between the intervention group and the
control group, when sufficient data were reported, by using
the RISKDIFF option of the FREQ procedure in SAS,
version 8.2 (SAS Institute, Cary, North Carolina). This
procedure uses a normal approximation to the binomial
distribution to construct asymptotic CIs.
Role of the Funding Source
This research was funded by the Agency for Healthcare
Research and Quality (AHRQ) under a contract to
support the work of the USPSTF. Members of the
USPSTF participated in the initial design and reviewed
interim results and the final evidence review. The AHRQ
had no role in study selection, quality assessment, or synthesis,
although AHRQ staff reviewed interim and final
evidence reports and distributed the initial evidence report
for external review of content by outside experts, including
representatives of professional societies and federal agencies.
The final published systematic evidence review on which this paper is based was revised on the basis of comments from these external reviewers.
Return to Contents
Results
We reviewed 1289 abstracts and 155 complete articles
for all key questions (Appendix Figure 2). Seventeen studies (9 RCTs27-35 and 8
CCTs36-43 reported in 17 articles met our inclusion
criteria (Table 1 and Table 2): 7 from the 1996 USPSTF review,
6 from other systematic reviews or outside sources,
and 4 from searches that were conducted for this review.
No study that met our inclusion criteria was related to
counseling about alcohol-related driving (key question 3)
or the harms of counseling (key question 4). Appendix
Tables 6 to 13 contain detailed
evidence on all included studies. Narrative descriptions
of individual included studies and a list of excluded
articles describing reasons for exclusion are available in the
full evidence report.22 Table 3 summarizes the overall
quality of evidence according to USPSTF criteria20 for
each key question.
Key Question 1
Do primary care behavioral counseling interventions for
children, adolescents, and adults to increase the correct use of
age- and weight-appropriate restraints and reduce driving/riding with drivers under the influence of alcohol reduce morbidity
and/or mortality from motor vehicle occupant injuries?
One large, fair-quality, group-level CCT (n=286,676) reported the direct effects of behavioral counseling
on the incidence of MVOIs among children from birth
to 5 years of age (Table 1).36 In the trial, interventions
targeting child safety seat use included behavioral counseling
components that were delivered in inpatient and primary
care settings. These components were tested in the
context of multiple, community-wide approaches to reducing
MVOIs and other injuries. Investigators measured
MVOIs through a hospital surveillance system during the
year before the study and for the 2 years during which the
injury prevention programs were conducted. During the 2
years of the programs, MVOI rates in the intervention
communities decreased, whereas those in the control communities
increased. The odds ratio of risk for MVOI during
the preintervention period, compared with the intervention
period, in the intervention communities was 2.78
times (95% CI, 1.66 to 4.66 times) as large as that for the
control communities, after adjustment for socioeconomic
status. Given the trial’s nature, however, the effect of the
clinical counseling components on MVOI reduction cannot
be separately determined from community-based approaches.
In addition, this trial was conducted in the early
1980s, when the Massachusetts state legislature was debating
a child automobile restraint bill and the baseline use of
child restraints was 49%, which is much lower than the
current prevalence of use. The effects of clinical counseling
about child safety seat use on MVOI in the current, widely
regulated environment remain untested. Similarly, we
found no study that reported health outcomes of counseling
interventions targeting the use of booster seats or safety
belts for older children, adolescents, or adults or of interventions
targeting alcohol-related driving for any age
group.
Key Question 2
Do primary care behavioral counseling interventions for
children, adolescents, and adults lead to increased correct use
of age- and weight-appropriate restraints?
All 17 included trials reported on the use or correct
use of age- and weight-appropriate restraints. Most of these
were published during the late 1970s or 1980s, before the
widespread enactment of child safety seat or safety belt
legislation. Overall, the trials addressed patient populations
of all ages, with the most extensive literature involving
infants and toddlers up to 4 years of age (6 RCTs27-32
and 7 CCTs36-42) (Table 1). One RCT33 focused
on booster seat use among children 4 to 7 years of age, and
3 trials targeted safety belt use among older children, adolescents,
or adults (1 CCT43 and 2 RCTs34,35)
(Table 2). Across all trials, the tested behavioral counseling
interventions comprised a wide range of educational approaches,
including counseling by clinicians, written materials,
films on automotive safety, live demonstrations of
child safety seat use, and group-level informational sessions.
Five trials included both educational components
and the distribution of a free or reduced-cost child safety
seat29,31,39,40 or booster seat.33 One trial included
education plus behavioral reinforcement components.28 Interventions were conducted in primary care
outpatient clinics and inpatient maternity wards (where
clinicians encounter mothers of newborn infants) or met
the criteria for being feasible for delivering in primary care
or for referral for primary care. Table 1 describes trials
among infants and children up to 4 years of age and stratifies
the studies by setting and time of delivery (antepartum
period vs. during well-child care). Interventions also varied
in other characteristics, such as who delivered the counseling
or the intensity of the counseling. All trials had methodological
flaws (7 fair-quality and 10 fair- to poor–quality
trials), and none were of good quality according to the
USPSTF criteria. Because trial characteristics were highly
heterogeneous and study quality was limited, we did not
quantitatively combine results across any of the trials.
Results varied widely among the trials targeting increased
use of child safety seats among infants and toddlers
up to 4 years of age. The largest absolute differences in use
between intervention and control groups (47% to 72%)
were reported in 3 of 4 trials that assessed interventions of
combined education with distribution of a child safety seat
(2 RCTs29,31 and 1 group-level CCT39). In these
trials, the interventions were delivered either during the
end of pregnancy or during the peripartum hospitalization to newly postpartum women. These large differences in use
or correct use were measured at the initial follow-up either
immediately after hospital discharge29,31 or 9 months
after the intervention.39 The effects were diminished at
subsequent follow-up measurements (1% to 43%). Several
methodological limitations may have led to an overestimate
of effect size among these trials. The 2 RCTs included
very small samples (n=14 and 30), and the third
trial measured outcomes by self-report, did not specify correct
use, and excluded 13% of infants eligible for the intervention
group because their caregivers did not accept the
car seat loan. In contrast to these findings, a fourth trial
that also assessed an intervention of education plus child
safety seat distribution reported a small difference in correct
use of child safety seats between the intervention and
control groups (absolute difference, 5% to 7%).40
Of the remaining trials targeting children up to 4 years
of age, 4 trials (3 fair-quality36,37 or fair- to poor-quality38 CCTs and 1 fair- to poor-quality RCT27)
evaluated counseling by pediatricians during well-child
care. Two trials measured follow-up at 2 months and reported
an increase in restraint use, ranging from an absolute
difference between the intervention and control group
of 13% to 21%.37,38 Trials that reported initial or
repeated follow-up later than 2 months reported that use
was similar between the intervention and control groups
(absolute difference, 2% to 6%).27,36,37 The remaining
trials targeting child safety seat use varied in setting,
when the intervention was delivered, and results, and each
had multiple methodological flaws (all were rated fair to
poor quality).28,30,32,42 Among the trials targeting
increased use of infant or child safety seats, a demonstration
of correct child safety seat use was an intervention
component of trials reporting larger increases in use or
correct child safety seat use. More specifically, among the 8
trials that included a demonstration of correct child safety-seat use,28,29,31,37,39-42 6 reported increases in
child safety seat use (absolute differences, 17.8% to 72%).28,29,31,37,39,42
Five trials did not include a
demonstration of correct use as part of the intervention,27,30,32,36,38
and only 1 of these (a fair- to poor-quality
CCT38) reported an increase in use.
Investigators of 1 fair- to poor-quality RCT evaluated
an intervention to increase the use of booster seats among
primarily low-income, African-American children 4 to 7
years of age.33 The intervention consisted of brief (5-minute) educational counseling by a certified car seat technician
in an emergency department setting, delivered either
with or without a free booster seat, and was compared with
a usual care control group. On the basis of self-reported
data at 1 month after the intervention was delivered, 98%
of families in the education plus distribution group reported
using a booster seat, compared with 5.5% of families
in the other 2 groups (control or education only) combined
(P <0.001). The trial had several methodological
problems that could have introduced bias, including high
overall attrition (35%), differential attrition across treatment
groups (40%, 39%, and 25%), self-reported outcomes,
and analysis of only the completers. In addition,
families who reported using a booster seat when presenting
to the emergency department were not eligible for inclusion.
Therefore, the magnitude of benefit from the education
plus distribution programs in a general primary care
population cannot be directly determined from these findings.
Investigators of 3 trials evaluated safety belt use among
children, adolescents, or adults. Of these, 1 fair-quality
CCT reported short-term improvement in observed seat
belt use in the intervention group compared with the control
group immediately after the intervention (38% vs. 5%; P <0.001), but investigators analyzed only children and
adolescents who were not wearing seat belts when arriving
to the visit.43 Investigators of the remaining 2 trials
measured seat belt use at 6 to 36 months of follow-up and
reported that use was similar between intervention and
control groups at these times.34,35 Among these trials,
the most intensive seat belt intervention was tested in the
Dartmouth Prevention Project,34 a large, fair-quality,
cluster-randomized RCT evaluating an office-based structured
prevention intervention delivered to 3145 fifth- and
sixth-grade children. Counseling by a pediatrician or nurse
practitioner during well-child care visits was supplemented
by a contract for a family policy, reinforcement of the
message at subsequent office visits over 36 months, written
materials mailed to the home, and telephone calls alternately
targeting the parent and child. No statistically significant
differences were found in the proportion of children previous month at the 12-, 24-, or 36-month follow-up
(odds ratios, 0.87, 0.96, and 0.89, respectively [all 95%
CIs include 1.0]).
For all age groups, the volume and quality of research
were inadequate to quantitatively address questions about
essential elements of efficacious interventions, other positive
outcomes from behavioral counseling interventions addressing
seat belt use, or maintenance of MVOI safety behaviors
after behavioral counseling interventions. The
complexity of the type of restraint device needed (for example,
child safety seat, booster seat, or safety belt) and
receptivity of the patient because of differences in age influence
the type of intervention that may be needed. These
issues were not specifically addressed in the studies.
Key Question 3
Do primary care behavioral counseling interventions for
children, adolescents, and adults reduce driving/riding with
drivers under the influence of alcohol?
Our searches found no studies of primary care interventions
evaluating behavioral counseling in general populations
to reduce driving while under the influence of alcohol
or riding with drivers who are under the influence of
alcohol.
Key Question 4
What are the adverse effects of counseling children, adolescents,
and adults to correctly use age- and weight-appropriate restraints and reduce driving/riding with drivers under the
influence of alcohol?
Our searches found no studies of adverse effects of
counseling to use age- and weight-appropriate restraints or
reduced driving while under the influence of alcohol or
riding with drivers who are under the influence of alcohol.
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Discussion
The evidence for reducing the risk for injury and death
when using recommended motor vehicle occupant restraints
has been previously demonstrated to be strong.
The current prevalence of restraint use is near the Healthy
People 2010 goal of 100% use for infants and is more than
90% for children age 1 to 3 years.44 Incorrect use,
however, remains common in these age groups and diminishes
the level of protection provided. Restraint use is less
prevalent among children 4 to 7 years of age, among whom
premature advancement to seat belts increases the risk for
injuries and among adolescents and adults (20% to 25%
nonuse in these age groups).45
The available scientific literature provides fair evidence
that, among infants and children up to 4 years of age,
behavioral counseling interventions have been effective in
increasing short-term correct use of infant and child safety
seats at the time of hospital discharge or within 2 months
after initially delivering the intervention. Effects have subsequently
diminished, in many cases because use increases
over time in groups without intervention. Many of the
successful interventions included a demonstration of correct
safety seat use. The largest effect sizes were seen among
the trials that included a safety seat distribution program
through a reduced-cost loan or giveaway program. Several
interventions that did not include distribution programs,
however, were also effective, at least in the short term.
Most of the studies included in this review had multiple
methodological flaws, and no study was of good quality
according to the USPSTF criteria. Some of the better-quality
trials that were most relevant to the primary care
setting were nonrandomized, controlled trials conducted
during the late 1970s to 1980s, when many states first began passing child seat restraint laws. Some studies reported
observed prevalence of correct use of child safety
seats in fewer than 10% of the study population. Awareness
and attitudes about restraint use differed greatly from
current awareness and attitudes. Experts in the field, including
authors of previous evidence reviews, have expressed
concern about the limited quality and lack of recent
studies in this body of evidence,19,20,46 especially
given the magnitude of public health burden.
Because of recently revised safety recommendations,
only 28 states currently have laws that apply to children in
booster seats, and most of these do not cover all children up
to age 8 years.10 We found few relevant data describing
the effectiveness of primary care clinician counseling of
children or parents on the use of booster seats. One recent
trial conducted in an emergency department setting demonstrated
a large increase in self-reported use among low income
families that received both education and a free
booster seat.33 The intervention, however, was delivered
by certified car seat technicians who had undergone intensive
training, and it required the distribution of a free
booster seat to be effective. Translating these findings to
the primary care setting is not yet tested. Few adequate-quality
trials have evaluated counseling to increase seat belt
use among older children, adolescents, and adults.
We found no research addressing the effect of behavioral
counseling interventions delivered to unselected patients
in primary care to reduce alcohol-related driving or
riding with an impaired driver. The USPSTF, however,
has previously recommended screening and brief interventions
for alcohol misuse in primary care,47 and these
interventions may also improve alcohol-related MVOIs.
Among the trials included in the systematic review on
primary care screening and interventions for risky and
harmful alcohol use that were prepared to support the
USPSTF recommendation,22 1 RCT found a reduction
in the self-reported rate of driving after drinking among
risky or harmful alcohol users who received an intervention
to reduce alcohol use.48 Another RCT of a similar intervention
reported a reduction in motor vehicle crashes
with nonfatal injuries in a subanalysis of adults 18 to 30
years of age.49 More than 80% of alcohol-impaired
driving episodes are reported by people who also reported
binge drinking.50 Thus, screening all patients for alcohol misuse and then intervening with risky and harmful
users (instead of counseling all primary care patients about
reducing alcohol-related driving) may be the best evidence-based
approach that is currently available for primary care
clinicians.
Interventions to reduce MVOIs are complex, involving
both regulatory approaches and behavioral counseling
through community-based and clinical settings. Furthermore,
the complexity of behavioral counseling approaches
changes as the individual ages (complex restraint systems
for infants and children, inherent risk-taking behavior for
adolescents, and established behaviors for adults). Although
primary care behavioral counseling interventions to increase
correct age- and weight-appropriate restraint use
among infants and toddlers may increase short-term use of
restraints, these effects may diminish over time. Effective
interventions included education, demonstration of correct
use, and child safety seat distribution programs and were
tested during a time of growing cultural support and increasing
regulatory requirements for child safety restraint
use. Data from primary care studies were lacking for interventions
to increase the use of belt-positioning booster
seats for children 4 to 8 years of age, an area where interventions
are needed because of lower use and gaps in current
child safety seat legislation. Similarly, no interventions
targeting drivers 16 to 24 years of age, a known high-risk
group, were available. Data describing the effects of behavioral
counseling interventions among adults were also limited.
Across age groups addressed, recent or good-quality
trials for any MVOI-related safety behaviors were lacking.
Many of the available studies were conducted when restraint
use was less common, and the studies in populations
with higher baseline use did not show improvements
in restraint use, suggesting a possible ceiling effect. Misuse
of child safety restraints remains common and diminishes
their effectiveness.
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