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Facilitators and barriers to child restraint use in motor vehicles: a qualitative evidence synthesis
  1. Soumyadeep Bhaumik1,
  2. Kate Hunter2,3,
  3. Richard Matzopoulos4,
  4. Megan Prinsloo5,
  5. Rebecca Q Ivers3,6,
  6. Margaret Peden3,7,8
  1. 1 Injury Division, George Institute for Global Health, New Delhi, India
  2. 2 Injury Division, George Institute for Global Health, Camperdown, New South Wales, Australia
  3. 3 School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia
  4. 4 School of Public Health & Family Medicine, University of Cape Town, Cape Town, Western Cape, South Africa
  5. 5 Burden of Disease Research Unit, South African Medical Research Council, Tygerberg, South Africa
  6. 6 Ivers, George Institute for Global Health, Camperdown, New South Wales, Australia
  7. 7 George Institute for Global Health UK, Oxford, Oxfordshire, UK
  8. 8 Nuffield Department of Womens and Reproductive Health, University of Oxford, Oxford, Oxfordshire, UK
  1. Correspondence to Margaret Peden, George Institute for Global Health UK, Oxford OX1 2BQ, UK; margie.peden{at}


Background Road traffic collisions contribute a significant burden of mortality and morbidity to children globally. The improper or non-use of child restraints can result in children sustaining significant injuries in the event of a collision. Systematic reviews on the effectiveness of various interventions to increase the use of child restraints already exist but to the best of our knowledge, there has been no qualitative evidence syntheses on the facilitators and barriers to child restraint usage. This review aims to fill that gap.

Methods We searched for qualitative studies, which focused on perceptions, values and experiences of children, parents/caregivers or any other relevant stakeholders on the use of restraints for children travelling in motor vehicles in PubMed, EMBASE and Global Health and screened reference lists of all included studies. We assessed the quality of included studies with the Critical Appraisal Skills Programme (CASP) checklist and used the PROGRESS Plus lens for an equity focused analysis.

Results We identified a total of 335 records from searching the databases and five records from other sources. After screening, we identified 17 studies that met our inclusion criteria. All but one study (which had children as participants) focused on the perceptions, attitudes and barriers of parents or caregivers. The included studies were from three high-income (n=14) and one upper-middle income (n=3) country. In addition, although many focused exclusively on participants from culturally and linguistically diverse minorities, the issue of equity was not well addressed. Five major themes emerged from the analysis. (1) perceived risk for injuries and perceived safety benefits of child restraint usage varies in different settings and between different types of caregivers; (2) practical issues around the use of child restraints is a major barrier to its uptake as a child safety measure; (3) restraint use is considered as a mechanism to discipline children rather than as a safety device by parents and as children became older they actively seek opportunities to negotiate the non-usage of restraints; (4) adoption and enforcement of laws shape perceptions and usage in all settings and (5) perceptions and norms of child safety differ among culturally and linguistically diverse groups.

Conclusion The results of this systematic review should be considered when designing interventions to promote the uptake of child restraints. However, there is a need to conduct qualitative research around the facilitators and barriers to child restraint usage in low-income and middle-income countries. Furthermore, there is a need for more evidence conducted in semiurban and rural areas and to involve fathers, policy-makers, implementers and enforcement agencies in such studies.

  • interventions
  • uptake/adherence
  • child survival
  • systematic review
  • child

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  • Twitter @rebeccaivers, @margiepeden

  • Contributors MP conceived the study and obtained the funding. SB designed, conducted, analysed and interpreted the data with input from KH, RM, RQI and MP. SB drafted the first manuscript with input from KH and MP. The final text was approved by all authors.

  • Funding This systematic review was funded through an Oxford University Internal HEFCE GCRF grant (ref no. 005105). KH was funded through a NSW Health Early Mid-Career Research Fellowship.

  • Competing interests KH authored one included study and therefore was not involved in data extraction or quality assessment.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting or dissemination plans of this research.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.