Assessment of caregiver-targeted interventions for use of motor vehicle passenger safety systems for children: A systematic review and meta-analysis

Importance: Caregiver-targeted interventions to improve use of child restraint systems (CRS) are common and heterogeneous in their implementation. The effectiveness of these interventions is unknown.

Objective: To quantify the effects of caregiver-targeted interventions using meta-analytic methods, assess the quality of published studies, and assess for publication bias.

Data Sources: PUBMED and PsychINFO (January 2004-April 2019) were searched for English-language studies using a list of search terms.

Study Selection: Studies met inclusion criteria if they included a caregiver-targeted intervention that focused on increasing CRS use for children (≤9 years) and reported restraint system use post-intervention.

Data Extraction and Syntheses: Cochrane and PRISMA Guidelines were used for the meta46 analysis and risk of bias review. Information was extracted on intervention type, setting, implementation, and attributes of the study independently between two coders. Data were pooled from independent samples with one outcome measure from each intervention implementation or study.

Main Outcome and Measures: This study was an exploratory random-effects meta-analysis. Unadjusted odds ratios (OR) were calculated using the sample size and the observed number of children in incorrect or correct restraints post-intervention to determine the odds of incorrect CRS use after completing an intervention. Setting, measurement method, randomization, use of vouchers, and types of restraint were tested as moderators. A funnel plot was used to assess for publication bias.

Results: Of 1,240 potential articles, 51 were deemed eligible for screening and 10 (n=8,238 participants total) were included in the meta-analysis. Caregiver-targeted interventions were associated with a reduction in the number of children not riding in a CRS (OR= 0.51, 95% CI:0.36, 0.71, p<0.001). Variance in the averaged effect size was driven by self-report methods (when removed from analyses, I² = 61.82%, R² change= 26.3, p= 0.02) and hospital settings (when removed from analyses, I²= 70.7%, R² change= 17.43, p= 0.002). Risk of bias was high in most studies, however there was low evidence for publication bias.

Conclusion and Relevance: In this meta-analysis, caregiver-targeted interventions were associated with a reduction in the number of children not riding in a CRS; however, the methodological rigor of intervention studies should be enhanced.