Cross-sectional analysis of car restraint system use during transportation of children with special health care needs in the Western Cape

• Main Author: Phillips, Kerry-Ann
• Other Authors: Corten, Lieselotte
• Format: Dissertation
• Language: English
• Published: Faculty of Health Sciences 2021
• Subjects: Physiotherapy
• Online Access: http://hdl.handle.net/11427/33926

Background: Road traffic injuries are the leading cause of death in children and young adults. Children are at increased risk of fatalities and serious injury due to the differences in their body segment proportions affecting their body kinetics in a vehicle accident. Serious injury and death can be reduced by the appropriate use of car restraint systems (CRS). Children with special health care needs (CSHCN), particularly children with poor postural control, may need adaptive seating to improve postural support and sitting ability within the vehicle due to their additional physical needs. Standard CRS might be unsafe or inappropriate for children with physical disabilities. Research Aims: The thesis aimed to understand the current CRS usage as well as the parents' experiences and perspectives of transportation of CSHCN in the Western Cape, and to determine the postural support needs of CSHCN and the suitability of different CRS designs to meet these needs during transportation. This was achieved through a survey study, followed by a cross-sectional study. Assessing the use of car restraint systems in children with special health care needs; a Western Cape based survey study Objectives: To determine the modes of transport and the prevalence of the use of postural support systems by CSHCN. Along with describing the current use of seatbelts, standard or specialised CRS and exploring the challenges faced by parents of CSHCN during transportation. Methods: A descriptive quantitative survey was performed amongst a convenience sample of all parents of CSHCN between the age of 4 – 18 years enrolled at three special needs schools in the Western Cape, South Africa. Parents had to be able to read and understand English or Afrikaans to be eligible for enrolment in the study. Focus group discussions were conducted to validate the self-designed questionnaire. Results: Parents of 268 children were enrolled in the study (median (IQR) age 11.52 (14.63- 8.86) years; 58.96% male). The most common diagnosis was cerebral palsy (CP) (29.10%), and most children were transported to school with public transport, including school bus (73.13%). The mode of transport was linked to the distance travelled and affordability, and each had its own challenges. The main challenges of parents using private transport were transporting the wheelchair (10.82%) and the unavailability of demarcated disability parking bays (7.46%). When using public transport parents identified their child's poor sitting balance (6.34%) and lack of space within the vehicle (5.60%) as the greatest challenges. The majority of children (58.96%) came from low-to-middle income households (< R6500 per month), significantly impacting the use of a CRS, with more children from higher income families being transported in a CRS (X²= 48.14, p< 0.001). Difficulties with sitting balance was reported in 25.75% of the children and was significantly association to the parents understanding of their child's sitting balance (X²= 17.72, p< 0.001). Parents who felt that their child had difficulty with their sitting balance were more likely to use a CRS. Furthermore, a significant association between currently using a CRS and child's weight was observed (X²= 11.54, p=0.021), as children who weighed more were less likely to still be using a CRS. Most parents (54.48%, n=146) did not know South Africa's current legislation on CRS, which was significantly associated with a lower CRS usage (X²= 19.84, p< 0.001). Half of the parents (n= 139, 51.87%) were not willing to spend money on a CRS as they felt that a car seat was not necessary for their child. The amount parents were willing to spend on a CRS was significantly associated with having ever made use of a CRS (X2=43.38, p< 0.001). Conclusions: Parents of CSHCN reported many challenges in transporting their child depending on the mode of transportation. CRS usage was associated with parent perception on the child's sitting abilities, lower weight, knowledge of legislation and a higher household income. Despite these, CRS usage amongst CSHCN is lower than expected as (48.88% – 55.22%) children that are still within the age and weight range to use a CRS as required by law did not report CRS usage. This could link in with the affordability of the CRS and failure to know the legislation on CRS by parents. This study highlights the need for national campaigns to promote and educate citizens on road safety and CRS legislation. Due to the lack of financial resources in low to middle income countries, it is vital that an affordable CRS is made available or is subsidized by the government where families are unable to afford the cost themselves, particularly for use in public transport. Effectiveness of currently available car restraint systems to maintain correct seating position during transportation for children with special health care needs Objectives: To determine the characteristics of CSHCN who require specialised CRS for their postural support needs, through assessment of their sitting ability and whether these needs are met by different CRS. Methods: Participants in the earlier survey study were invited to take part in a crosssectional and pre-post design study. A screening tool for identifying sitting balance problems was developed and found to be reliable for inter- and intra-rater reliability (k>0.700, p0.879). This tool was used to identify CSHCN who had difficulty sitting independently on different types of seats. These participants underwent a standardised sitting balance assessment, using the Level of Sitting Scale (LSS), to identify eligible participants with postural support needs. Participants were excluded if they recently had surgery or had an unstable health condition which could alter their sitting balance. The ability of two standard CRS (Car Seat and Booster seat), two Specialised CRS (one locally and one internationally produced), and Seatbelt only to provide adequate postural support was investigated. Head and trunk postures were analysed and categorised, by deviation from the midline, by photographs taken from different viewpoints. Results: There were 78 CSHCN enrolled in the study (mean (SD) age 11.50 (3.70) years; 65.75% male), the most common diagnosis was CP (63.48%), the majority of participants did not require any support to maintain sitting balance and were categorised as levels 5-8 of the LSS (78.08%). According to the World Health Organisation anthropometric guidelines 54.79% (n=40) of the participants should still use a CRS, either a Booster Seat (42.47%, n=31) or a Car Seat (12.33%, n=9). The head or torso fully supported and between the side supports of the CRS was the most common posture in all the viewpoints of the different CRS except for the lateral head viewpoint of the CRS Car Seat (50.00%; n=4), the Booster Seat (60.00%; n=18), and the International Specialised CRS (60.61%; n=20), as well as the anterior torso viewpoint of the Seatbelt only (50.75%; n=34). The CRS that resulted in the largest proportion of unacceptable posture deviations from the standard position were the Seatbelt only (20.90%, n=56) and the Booster Seat (18.33%, n=22). Out of position (OOP) postures were observed in all the devices for the anterior and lateral head positions (3.03% - 20.00%). The Booster Seat, the Local Specialised CRS and the Seatbelt only devices had participants with OOP postures in all four viewpoints. A key observation in the current study is the lack of torso support for the majority of CSHCN in the anterior torso viewpoint of the Seatbelt Only CRS (55.22%, n=37), indicating that the use of a Seatbelt only does not provide adequate postural support for all CSHCN despite them meeting WHO anthropometric requirements. No significant association was found between the pre- and post-test postural analysis scores of the Seatbelt only (X2=2.14, p=0.144) which could be as a result of the large postural deviations pre-testing (41.79%, n=28) remained post-testing. However, there was a significant association between the preand post-test scores of the anterior head viewpoint of the Booster seat (X2= 7.94, p=0.005), indicating lateral head deviation. The post-test postural analysis score of the Booster Seat anterior head viewpoint was significantly associated with a deviated posture (X2= 7.94, p=0.005). Other OOP observations included postures that could not be categorised by head and trunk deviation from the midline including head or torso rotation, abnormal limb placement, body extension and slouching. Overall performance scores are a sum of the number of viewpoints where the CSHCN posture worsens post-test. an indication of the number of CSHCN whose posture worsened post-test in each of the viewpoints of the CRS. Although there was no correlation between the LSS score and the overall performance score of any CRS device which would indicate if the CSHCN balance influences CRS performance, the Booster Seat (80.00%, n=24) and the Seatbelt only (55.23%, n=37) devices had the greatest number of participants with a poor overall performance. The viewpoints which had the worst performance scores were the anterior and lateral head of the Booster Seat (46.67%, n=14 and 43.33%, n=13 respectively) and both viewpoints had majority of participants worsen their scores. All CRS performed adequately in the lateral torso viewpoint, indicating sufficient support of the torso in the sagittal plane. Conclusions: The postural support needs of CHSCN are unique and depend on the child's anthropometry and the severity of their disability. The currently available CRS designs may not provide the postural support needed for many CSHCN. Postural deviations of the head, torso and limbs were observed which could be dangerous in the event of an accident. This study was not able to determine specific characteristics of CSHCN that require specialised CRS, as there was no association between the LSS and the overall performance score for any of the CRS devices. However, devices that offer less head and torso lateral support, or do not offer additional harness support such as the Seatbelt Only and the Booster Seat showed the largest proportion of OOP postures in CSHCN. Thesis Conclusion: This thesis highlights the complex transportation needs of CSHCN in South Africa and how the different CRS can influence posture. Additional observational research is required to determine the CRS usage in the CSHCN population to compare to the prevalence of CRS usage found in this survey study. Future research could incorporate other specialised CRS designs, particularly ones that are suitable for CSHCN beyond standard CRS weight and height limits or those with severe physical limitations that could not be tested during this study's simulated course. Practitioners prescribing and advising parents on CRS devices for the safe transportation of CSHCN should integrate thorough patient assessment and knowledge of manufacturer CRS design specifications to promote CRS usage. Policies should consider and accommodate for the challenges faced by CSHCN and their families in accessing, affording and utilising transport services. Advocacy and education programs should be combined with legislation enforcement to support improved implementation of CRS usage amongst all children, regardless of their disability status. For effective implementation for CSHCN, CRS should be affordable, accessible, functional and accommodate growth and postural support needs.