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Revista de Saúde Pública

On-line version ISSN 1518-8787Print version ISSN 0034-8910

Rev. Saúde Pública vol.43 n.5 São Paulo Oct. 2009  Epub Sep 11, 2009 



Child safety restraint use among children attending day care centers


Utilización de asientos de seguridad por niños matriculados en guarderías



Sergio Ricardo Lopes de OliveiraI, II; Maria Dalva de Barros CarvalhoI; Rosângela Getirana SantanaIII; Gabriela C S CamargoI; Ludmila LüdersI; Simone FranzinI

IDepartamento de Medicina. Universidade Estadual de Maringá (UEM). Maringá, PR, Brasil
IIPrograma de Pós-Graduação em Saúde Pública. Faculdade de Saúde Pública. Universidade de São Paulo. São Paulo, SP, Brasil
IIIDepartamento de Estatística. UEM. Maringá, PR, Brasil





OBJECTIVE: To estimate the prevalence of child safety restraint use and factors associated.
METHODS: Observational cross-sectional study using a stratified sampling conducted in the city of Maringá, Southern Brazil, between March and May 2007. Each day care center was visited at one day only. The outcome was use of child safety restraints by children under four. Vehicles (N=301) driving children under four were approached and information was collected using semi-structured questionnaires. Variables regarding child and adult seat distribution, use of safety restraints by occupants and driver's gender were analyzed. Data analyses included Fisher's exact test, Mantel-Haenszel chi-square test, and logistic regression.
RESULTS: Of the drivers approached, 51.8% were using seat belts (60.4% among women, 44.9% among men). Among children, 36.1% were using child safety seats, 45.4% were unrestrained during traveling, 16.0% were seated on an adult lap, and 2.7% were using seat belts. The logistic regression showed the following factors affecting child safety restraint use: child age under 15 months (OR = 3.76); seat belt use by the driver (OR = 2.45); and children from socio-occupational condition with higher income and education (OR = 1.37).
CONCLUSIONS: Child safety restraint use was associated to child age, seat belt use by the driver, and socio-occupational condition of day care centers. The finding of low rates of child safety restraint use poses a challenge to preventive medicine in Brazil, requiring attention and action to promote its widespread use.

Descriptors: Child. Accidents, Traffic, prevention & control. Seat Belts, utilization. Protective Devices. Cross-Sectional Studies.


OBJETIVO: Estimar la prevalencia de utilización de asientos de seguridad infantil y factores asociados.
MÉTODOS: Estudio transversal observacional, con muestreo estratificado, realizado en 15 guarderías de la ciudad de Maringá (Sur de Brasil), entre los meses de marzo y mayo de 2007. Cada guardería fue visitada en sólo un día lectivo. El resultado considerado fue la utilización de asiento de seguridad infantil por niños de hasta cuatro anos de edad. Carros (N=301) que transportaban niños menores de cuatro anos de edad fueron abordados y las informaciones fueron colectadas por medio de cuestionarios semi-estructurados. Las variables relacionadas a distribución de adultos y niños en los asientos del vehículo, situación de restricción de adultos pasajeros y niños y sexo del conductor fueron analizadas. Para análisis de los datos se aplicó la prueba exacta de Fisher, ji-cuadrado de Mantel-Haenszel y regresión logística.
RESULTADOS: Entre los conductores abordados, 51,8% usaban cinturón de seguridad (60,4% de las mujeres, 44,9% de los hombres). Entre los niños, 36,1% usaban asientos de seguridad infantil, 45,4% eran transportadas sueltas, 16,0% estaban en las piernas de adultos, 2,7% usaban el cinturón de seguridad. Según la regresión logística, los factores que más influenciaron el uso de asientos de seguridad infantil fueron: edad del niño inferior a 15 meses (OR=3,76), uso de cinturón de seguridad por el conductor (OR= 2,45) y niños pertenecientes a los estratos sociocupacionales de mayor renta y escolaridad (OR=1,37).
CONCLUSIONES: La utilización de asientos de seguridad infantil se mostró asociada a la edad del niño, uso de cinturón de seguridad por el conductor y estrato sociocupacional de la guardería. Frente al bajo índice de utilización, el uso de los asientos de seguridad infantil surge como desafío a la medicina preventiva en Brasil, exigiendo atención y actuación para su diseminación en la población.

Descriptores: Niño. Accidentes de Tránsito, prevención & control. Cinturones de Seguridad, utilización. Equipos de Seguridad. Estudios Transversales.




Traffic accidents has become a growing cause of mortality in Brazil, following the same trend seen in more developed coutries.2,8 Child safety seats (CSS) or child safety restraint systems (CSRS), popularly known as "car seats," are indented to minimize deaths and potential sequelae among child passengers in motor vehicles. The proper use of CSRS can prevent deaths or irreversible injuries.1,12,23 However, their use is not mandatory in many countries and use rates are very low in some of them.20 Even in countries where this issue has been widely disseminated, most of the children killed in traffic accidents were not using any safety restraints.14 In Brazil there are no published data on CSRS use. Although the need of CSRS use was addressed in the Brazilian Motor Vehicle Code,ª it did not include specific regulations on that. But the Conselho Nacional de Trânsito (Contran - Brazilian National Motor Vehicle Council)b Resolution No. 277/2008 of July 2008 provided clear requirements for CSRS use in accordance with international regulationsc establishing CSRS appropriate to the child's age and weight (Table 1).

There have recently been in the Brazilian literature review studies on CSRS use regulations,15,21 book chapters,9,22 and preliminary research studies.16,17 Oliveira et ald investigated the level of parental knowledge on CSRS use regulations, and higher rates were seen among those with higher socio-occupational conditions (schooling and income) .

The objective of the present study was to estimate the prevalence of child safety seat use and to analyze factors associated.



An observational cross-sectional study with stratified sampling was conducted in the city of Maringá, southern Brazil, between March and May 2007. The city is the third largest urban center in the state of Paraná and was divided into three socio-occupational areas based on income, schooling, and family head's occupation according to the Observatório das Metrópoles (Observatory of the Metropolises)e studies in the metropolitan area of the city.

Each of the three socio-occupational areas had public and private day care centers comprising six (A-F) strata as follows: A - private day care centers in an area of high income and schooling; B - private day care centers in an area of middle income and schooling; C - private day care centers in an area of low income and schooling; D - public day care centers in an area of high income and schooling; E - public day care centers in an area of middle income and schooling, F - public day care centers in an area of low income and schooling. However, a previous study17 reported that 62.4% of children taken in motor vehicles to day care centers belonged to the subset comprising the three strata of private day care centers (strata A, B and C) and the stratum of public day care centers of a socio-occupational area of high income and schooling (stratum D). Thus, the target-population of the present study was drawn from these four strata comprising 1,005 children attending 32 day care centers with nursery and pre-kindergarten services for children aged zero to four years.17 It was estimated a sample size of 283 children with 5% error and 95% confidence interval. The stratified sampling was proportionate to the population size of each stratum. Data was collected first at the largest day care center in the stratum, followed by all other centers in a descending order by number of children until the sample at each stratum was achieved (Table 2).



Each day care center was studied at one single day and only the center's principal was previously informed on the date of data collection. During arrival time of children, in the early morning and early afternoon, vehicles driving children were approached and drivers were invited to participate in the study. Only those vehicles with children younger than four were eligible to participate in the study. For each vehicle, two previously trained data collectors would apply pre-tested semi-structured questionnaires.16 These instruments were developed to collect information on gender of vehicle occupants, seat belt use by the driver, child and adult seat distribution, child and adult passenger use of safety restraints and child safety restraint use. Excluding the driver's seat, four passenger seats were considered: A - front seat; B - rear seat opposite to the driver's; C - central rear seat; D - rear seat right behind the driver's.

For data collection, one of the collectors would approach the driver explaining the study and the consent form. It was then collected information on the child's gender, age and weight, and the driver's and all other adult passenger's gender. At the same time, a second collector would observe the driver's and passenger's safety restraint status and their seat distribution in the vehicle. Children status as for seat restraint was categorized into four different situations: unrestrained; seated on an adult lap; using a seat belt; or using CSRS. The methodology of approach and data collection instruments were detailed elsewhere.16

Data analysis was carried out using Fisher's exact test through SAS program 9.1, and Mantel-Haenszel chi-square test through Epi Info 3.5.1, and logistic regression through Statistica 7.1.

The study was approved by the Research Ethics Committee of Universidade Estadual de Maringá (Protocol No. 271/2006).



Data were collected at 15 day care centers (Table 2) and all centers agreed to participate in the study. Of 370 vehicles approached, 301 were driving eligible children. There were 324 children aged zero to four years, 37 aged four to ten and 136 adults, totaling 798 individuals. There were on average 2.65 persons per vehicle. As for gender, 51.8% of the drivers were males. Of all drivers, 51.8% were using seat belts (60.4% of females and 44.9% of males). Of 324 children eligible, 51.9% were males, 42.9% were females and gender was not recorded (unknown) in 5.3%. Most children were older than 12 months old (89.2%).

CSRS use rate was 36.1%; 45.4% of children were unrestrained, 16.1% were seated on an adult lap, and 2.7% were using a seat belt. Of those children using CSRS, 89.7% were in a car seat, 5.1% in a baby carrier, 3.4% in a backless booster seat, and 1.7% in a high-back booster seat.

The univariate analysis showed that CSRS use was associated to: the child's age; child's category by age and weight; the driver's gender; seat belt use by the driver; correlation between seat belt use and driver's gender; seat position; stratum of day care center; number of passengers in the vehicle; and presence of a second child and adult passengers (Table 3). The child's gender did not affect CSRS use.

Given the statistical relevance of multiple variables, it was performed a logistic regression with variables regrouped by their significance in the univariate analysis. The results showed factors associated to CSRS use: children aged between 0 and 0+; subset of day care centers of strata A and B; and seat belt use by the driver (Table 4). In the logistic regression, the variable seat position in the vehicle was excluded due to the fact that no children using CSRS were in the front passenger seat, producing a variable with no variance.




Despite widespread information on mandatory use of seat belt in Brazil, only half the drivers were using it. The finding of low rates of CSRS is not surprising as this issue has been little explored in studies and poorly disseminated among Brazilians. Only 36.1% of the children were using any CSRS; 45.4% were unrestrained in the vehicle and were more susceptible to be ejected out of the vehicle and collide against other passengers and parts of the vehicle in the event of an accident, sudden breaking or curves. Unrestrained children may have inappropriate risky behaviors: get into the driving area, interfere with door and window opening/closing, and put parts of their own body outside the vehicle.13

The design of the present study did not allow to analyzing potential inappropriate fitting of CSRS in the vehicle or inadequate use of CSRS restraining belts or whether children using CSRS were correctly seated. It is noteworthy the finding of 46 children under four seated in the front seat with no CSRS. Although apparently contradictory, Contran's Resolution No. 277/08 allows that, in vehicles with no rear seat such as small pickup trucks, children can be seated in the front passenger seat using CSRS or seat belt when appropriate.f Aware of the need of not leaving their children unrestrained, some parents had them inappropriately held on an adult lap (16.1%) while others inappropriately used seat belts to restraint them (2.7%). Inappropriate early use of seat belt makes children more susceptible to abdominal and vertebral injuries (seat belt syndrome).4,23

Corroborating international data, CSRS use proved to be inversely proportional to the child's age3,10 and was associated with the seat belt use by the driver.5 The higher rate of CSRS use in day care centers located in strata A and B (Table 4) was most likely due to higher schooling and income of the population attending these centers, as indicated in the multivariate analysis and logistic regression.

The association between the driver's gender and seat belt use indicated that the presence of restrained female drivers in the vehicle favored CSRS use (OR= 3.45). Among unrestrained male drivers, 81.7% of children were also unrestrained, suggesting that negligence with one's own safety was reflected in the child's care. In the present study, even among parents with higher schooling and income (strata A and B) who could afford private day care centers and CSRS, CSRS use rates were lower than those reported in developed countries.1,9

The high cost of several CSRS models has been investigated in studies including less privileged populations and they showed that strategies facilitating access to CSRS, together with education activities, can promote a significant increase in CSRS use. The mandatory use of CSRS is an important legal factor but it is not enough for compliance.6,7,11,18,19,24

Given low rates of CSRS use associated to slightly low rates of seat belt use by the drivers and the recent implementation of specific CSRS legislation, CSRS use is a challenge to preventive medicine in Brazil, requiring action focusing on raising awareness of safety transportation rules for children. Further studies are needed for developing strategies to promote CSRS use as a way to prevent injuries and deaths in children passengers of vehicles.



To the City Department of Education of Maringá and the Sindicato das Escolas Particulares de Educação Infantil do Noroeste do Paraná (SINFANTIL/NOPR - Union of Private Child Education Schools of northeastern Paraná) for their approval of the study, and the Sociedade Eticamente Responsável de Maringá (SER Maringá - Maringá Ethically Responsible Society) for material preparation for data collection.



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Sergio Ricardo Lopes de Oliveira
Departamento de Medicina da Universidade Estadual de Maringá
Av. Mandacaru, 1590, Vila Mandacaru
87083-240, Maringá, PR, Brasil

Received: 7/24/2008
Revised: 12/13/2008
Approved: 2/18/2009



Artigo baseado na dissertação de mestrado de Oliveira SRL, apresentada ao Programa de Pós-Graduação em Ciências da Saúde da Universidade Estadual de Maringá, em 2007.
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