title: Misuse of booster cushions among children and adults in Shanghai-an observational and attitude study during buckling up.
abstract: Traffic crashes are one of the leading causes of fatalities among Chinese children. Booster cushion usage in China is low, and there are no studies showing how a population with limited experience handles booster cushions during buckling up. The purpose of this study was to evaluate the handling of and explore the attitudes toward booster cushions among children, parents, and grandparents in Shanghai.
  
  
  
  An observational study including a convenience sample of 254 children aged 4-12 years was conducted in 2 passenger cars at a shopping center in Shanghai. Parents, grandparents, or the children themselves buckled up the child on 2 types of booster cushions, a 2-stage integrated booster cushion (IBC) and an aftermarket booster cushion (BC). The test participants were observed during buckling up, first without and then with instructions. The test leaders conducted structured interviews.
  
  
  
  Ninety-eight percent of the uninstructed participants failed to buckle up without identified misuse on the aftermarket booster cushion and 31% of those uninstructed on the integrated booster cushion. The majority of misuse was severe, including placing the belt behind the arm and the lap belt routing above the guiding loops. Instruction reduced misuse to 58% (BC) and 12% (IBC), respectively, and, in particular, severe misuse. Some misuse was related to limited knowledge of how to buckle up on the booster cushion, and some misuse was intentional in order to reduce discomfort. The participants, both children and adults, reported that they preferred the IBC due to good comfort and convenience. Safety was reported as the main reason for adults using booster cushions in general, whereas children reported comfort as the most important motivation.
  
  
  
  Education is needed to ensure frequent and correct use of booster cushions in China and to raise safety awareness among children and adults. Furthermore, it is important that the booster cushions offer intuitively correct usage to a population with limited experience of booster cushions. This is the first study published on the handling of and attitude toward booster cushions after child restraints laws were introduced in Shanghai 2014.
authors.affiliation: a Autoliv Research , Vårgårda , Sweden.|b Karolinska Institutet , Department of Clinical Neuroscience , Stockholm , Sweden.
authors.forename: Katarina
authors.initials: K
authors.lastname: Bohman
authors.affiliation: a Autoliv Research , Vårgårda , Sweden.
authors.forename: Sofia
authors.initials: S
authors.lastname: Jorlöv
authors.affiliation: c Autoliv , Shanghai , China.
authors.forename: Shengqi
authors.initials: S
authors.lastname: Zhou
authors.affiliation: c Autoliv , Shanghai , China.
authors.forename: Cloud
authors.initials: C
authors.lastname: Zhao
authors.affiliation: c Autoliv , Shanghai , China.
authors.forename: Bo
authors.initials: B
authors.lastname: Sui
authors.affiliation: c Autoliv , Shanghai , China.
authors.forename: Chengkai
authors.initials: C
authors.lastname: Ding
mesh_terms: D000328:Adult; D001290:Attitude; D002648:Child; D057207:Child Restraint Systems / Q000706:statistics & numerical data*; D002675:Child, Preschool; D002681:China; D000066502:Grandparents / Q000523:psychology*; D006801:Humans; D010290:Parents / Q000523:psychology*; D012449:Safety / Q000331:legislation & jurisprudence; D012622:Seat Belts / Q000331:legislation & jurisprudence / Q000706:statistics & numerical data*
keywords: China; attitude; booster cushion; handling; integrated booster cushion; misuse