Comparative analysis of child restraint system use in nine cities: a multiround cross-sectional observational study

Introduction: Road traffic injuries are a leading cause of death in children worldwide. Over 90% of road traffic deaths occur in low-income and middle-income countries. Unfortunately, there is very little data on child restraint system (CRS) use in major regions globally. Using data from nine cities, the objectives of this study were to examine the prevalence of CRS and how this has changed over time, and to investigate factors associated with CRS use. Methods: The nine cities included in the analysis were Accra, Addis Ababa, Bandung, Bangkok, Bogota, Fortaleza, Ho Chi Minh City, Mumbai and Sao Paulo. This was a cross-sectional study, with eight rounds of roadside observational data collected from February 2015 to March 2019. Results: There were 34 247 child passengers between the ages of 0-12. The overall prevalence of CRS use was 37.07% for children under 5 and 7.54% for children over 5. Sao Paulo had the highest overall prevalence of CRS use under 5 (40.08%) while Bandung had the lowest (1.25%). Only Mumbai had a significant increase in CRS use over time. Child passengers had higher odds of using CRS if they were younger, in the rear seat, with fewer passengers in the vehicle, and if the driver was wearing their seatbelt. Conclusions: The prevalence of correct utilisation of CRS is concerningly low and shows large variation globally. This study highlights the urgency of implementing a multifaceted approach to reach the Second Decade of Road Safety Goal of increasing child restraint use to close to 100% by 2030.