Background

MVC-related injury is among the leading causes of injury-related death in the USA. In 2012 alone, MVCs accounted for over 33 000 deaths.1 The development of seat belts, airbags and other safety devices, as well as legislation mandating seat belt use have been very effective at reducing MVC-related morbidity and mortality among adult populations.2 ,3 Similarly, strong evidence supporting the use of child seats has helped to establish such devices as the status quo for the youngest of children (typically ages 0–3 years), leading to dramatic reductions in MVC-related injury among children in that age group when compared with unrestrained children (OR: 2.7, 95% CI 2.40 to 3.1).4 ,5 Indeed, developments such as these have been among the great public health successes of our time.6

Adequately protecting older children, however, has proven to be more challenging. Traditional adult seat belts are designed to rest low on the hips, holding the pelvic bones in place in the event of a collision. When children are restrained in adult seat belts, the lap belt can ride up onto the child's abdomen during a crash, increasing the risk of a so-called ‘fulcrum’ fracture of the lumbar spine or other internal injuries.7 ,8 Such injuries can lead to paralysis or even death.

In response to this risk, belt-positioning booster seats have been developed. These devices, now widely available, have been shown to reduce the risk of serious injury among 4–8-year-old children by up to 45%, and professional groups such as the American Academy of Pediatrics have encouraged their use.9–11 Accordingly, most states (48 states, as of January 2014) have developed legislation requiring the use of age-appropriate restraints, including booster seats, in motor vehicles.12

While state laws on the subject are consistent in many aspects, there is significant variation in the upper age included in booster seat mandates (figure 1); the national mean age cut-off is 6.4 years, and the median is 7 years.13 On the older end of the age range, several states require booster seats to be used until age 8. However, Florida, until 2014, required no specialised restraint after age 3. This was the lowest age requirement among child passenger restraint laws in the 50 states.

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Figure 1

Distribution of state booster seat age requirements by age. The distribution of age requirements for state booster seat laws. Ages shown are inclusive (eg, children up to and including age eight are required to use booster seats).

This article presents a case report of the events leading up to and surrounding the passage of a booster seat law in Florida.

Efforts to change Florida law

Several iterations of what has been dubbed the ‘booster seat bill’ had been considered in the Florida Legislature since the Junior Leagues of Florida first advocated for it in 2001. The bill's supporters demonstrated their dedication and work ethic in each year's effort, but the endeavour was missing some key components, including effective reference documents for legislators and a broad base of vocal support, as outlined below. A new bill was introduced in the 2014 legislative session.14 That bill initially mandated the use of approved child booster seats up to either age 7 or specified height and weight requirements.

Components of Florida advocacy efforts

Organisers supporting the 2014 booster seat bill had worked hard to establish a broad-based coalition of support for the bill. The Florida Booster Seat Coalition counted among its members the Junior Leagues of Florida, Florida Medical Association, the Florida Hospital Association, the Florida Trial Attorneys Association, several local governments and school districts, hospitals, fire districts and businesses such as the American Automobile Association (AAA). With over 60 member organisations throughout the state, the Coalition represented many thousands of Floridians.

Policy interventions can be easier to pass when precedent exists in other jurisdictions.15–17 The Coalition wisely designed their bill to resemble current laws in neighbouring states (eg, Tennessee and Georgia), and pointed to regional political and cultural similarities for support.

What was missing

The breadth of the Coalition had been the chief asset of bill supporters, but many of the organisations were members in name only; aside from a handful of ardent supporters, few members actively participated in the legislative effort.

The bill's supporters were also keenly aware that a successful policy change would require convincing data, and they remained ready to provide a number of statistics from the relevant literature when asked. Without an effective issue brief or convincing ‘leave-behind’ material, recruiting neutral legislators to the cause proved a difficult task. Such a document would provide a concise and effective message to the target audience in a manner most useful for policymakers.

The successful approach

After 13 years of failed attempts, the 2014 legislative session saw the successful passage of a booster seat bill in both houses of the Florida Legislature. Governor Rick Scott signed the bill into law on 24 June of the same year.

For the 2014 session, bill supporters addressed the missing pieces of their previous approach. First, we (RSH and MBH were among the supporters) conducted a literature review and gathered data on MVC-related morbidity and mortality from the CDC's Web-based Injury Statistics Query and Reporting System (WISQARS) and from the Fatality Analysis Reporting System (FARS) of the National Highway Traffic Safety Administration (NHTSA). We then analysed those data to identify fatal and non-fatal trends. Floridians with personal stories about child passenger safety were identified through personal connections and by reaching out through online social networks such as Facebook. Over a 2-month period in late 2013, we combined their stories and pictures with statistics from both the analysis and the literature review into a single cohesive, readable document. Due to the extensive use of the term ‘booster seat’ in past unsuccessful attempts, we avoided the use of the term when compiling the document (as in all other communications). On behalf of the Florida Booster Seat Coalition, we then distributed that document, during face-to-face meetings and via email, to Florida state legislators and stakeholders known to have an interest in child passenger safety. The bill's sponsor, Representative Keith Perry, also distributed the document.

Second, the Booster Seat Coalition translated the diversity of its membership into a loud voice for change. While the leadership of the Florida Medical Association and Florida Osteopathic Medical Association opted not to actively support the bill, the student members of those organisations, recruited through the student-level governance of those bodies, were eager to offer their support. Students from Florida's eight medical schools contacted key committee chairs throughout the 2014 legislative session to encourage the bill's addition to committee agendas; these new voices, combined with those of the persistent activists who had kept the movement going for well over a decade, were able to persuade key policymakers, including committee chairs, to move the bill forward.

Third, and perhaps most critical, the importance of booster seat use for older children was effectively brought to the attention of the governor. After years of gubernatorial disinterest, bill supporters reached out to the campaign office of influential former Florida Governor Charlie Crist in February 2014. Governor Crist, who was engaged in a close race for a new term as governor, was responsive and eager to support an issue that was clearly important to the variety of organisations represented by the Florida Booster Seat Coalition. His responsiveness sparked the interest of his opponent, incumbent Governor Rick Scott. Within weeks of Governor Crist's commitment to support the booster seat bill, the office of Governor Scott invited the bill's sponsor to discuss the issue. The Governor's strong support that followed brought with it support from the speaker of the Florida House and the Senate president, virtually ensuring the bill's success.

Compromise along the way

Despite strong support for the Senate companion bill as originally introduced, HB 225 faced some difficulty in committee. Some legislators were hesitant to embrace the perceived complexity of some of the more detailed clauses contained in other state booster seat laws, including height and weight requirements for children to be covered. Unlike their colleagues in the Senate, House committee chairs responsible for setting meeting agendas were hesitant to raise the age requirement for booster seats by as much as 5 years. After continued debate, the bill was brought up for discussion in committee, but only after it was amended to lower the age requirement from 8 years to 5 years. The prospect of raising the age limit via amendment in the 2015 legislative session was agreed upon as a means of compromise.

Senate supporters were initially reluctant to weaken their bill after garnering support for the original language that included children up to 8 years. As a result, for a short period in April, the impasse threatened to end the bill's prospects altogether. In the end, however, all parties agreed that raising the requirement to 5 years represented a meaningful improvement over current statute, and both bills were amended accordingly. Amendments to raise the age above 5 years are currently being drafted.