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Multimodal Intervention and Child Passenger Safety Guideline Adherence in Young Children: A Sequential,
Michelle L Macy1,2, Bethany Pollock1, Sadiqa Kendi3
1Mary Ann & J. Milburn Smith Child Health Outcomes, Research and Evaluation Center, Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.
Insights
The Tiny Cargo, Big Deal, Abróchame Bien, Cuídame Bien (TCBD/ABCB) intervention improved child passenger safety guideline adherence. This remote precision prevention strategy showed lasting effects in caregivers adherent at 6 months.
Area of Science:
- Public Health
- Pediatrics
- Behavioral Science
Background:
- Suboptimal child passenger safety behaviors are prevalent despite available child restraint systems (CRS).
- National guidelines and state laws mandate the use of CRS for child passenger safety.
Purpose of the Study:
- To compare the Tiny Cargo, Big Deal, Abróchame Bien, Cuídame Bien (TCBD/ABCB) intervention with enhanced usual care (EUC) for 6-month guideline adherence.
- To assess the 12-month maintenance effect of the intervention.
- To evaluate outcomes from a sequential, multiple-assignment, randomized trial (SMART) phase 2 based on intervention intensity.
Main Methods:
- A randomized clinical trial using a SMART design was conducted across four sites in Chicago, Illinois.
- Eligible caregivers (aged 6 months to <11 years) spoke English or Spanish, owned a smartphone, and reported suboptimal safety behaviors.
- Phase 1 compared basic TCBD/ABCB (remote motivational interviewing [MI] + mobile health [mHealth]) with EUC. Phase 2 involved rerandomizing nonadherent participants to high-intensity or low-intensity interventions.
Main Results:
- At 6 months, 47.1% of caregivers receiving TCBD/ABCB were guideline adherent versus 32.2% receiving EUC (absolute difference, 13.1%; P=.007).
- Twelve-month follow-up showed significant maintenance effects (adjusted prevalence difference, 39.2%; P<.001).
- In phase 2, high-intensity TCBD/ABCB showed no significant difference compared to low-intensity TCBD/ABCB (adjusted prevalence difference, -3.9%; P=.59).
Conclusions:
- The TCBD/ABCB intervention significantly improved adherence to child passenger safety guidelines.
- The intervention demonstrated lasting effects for caregivers who were adherent at the 6-month mark.
- This remote, precision prevention approach may be adaptable for addressing leading causes of child mortality in various settings.
Importance:
Suboptimal child passenger safety behaviors are common despite the availability of effective child restraint systems (CRS), with national guidelines promoting-and state laws requiring-their use.
Objective:
To compare 6-month guideline adherence following the Tiny Cargo, Big Deal, Abróchame Bien, Cuídame Bien (TCBD/ABCB) intervention vs enhanced usual care (EUC); assess 12-month maintenance effect; and evaluate sequential, multiple-assignment, randomized trial (SMART) phase 2 outcomes by intervention intensity.
Design, Setting, And Participants:
This randomized clinical trial using a SMART study design was conducted at 1 pediatric emergency department (ED), 1 community ED, and 2 urgent care centers in metropolitan Chicago, Illinois, from February 2020 to August 2022. Eligible caregivers spoke English or Spanish, lived in Illinois, owned a smartphone, traveled weekly with their child (aged 6 months to younger than 11 years), and reported suboptimal child passenger safety behaviors. Of 5416 caregivers who were screened, 1517 were potentially eligible. Data analysis occurred from October 2024 to March 2025.
Interventions:
Phase 1 included basic TCBD/ABCB (remote motivational interviewing [MI] plus tailored mobile health [mHealth]) vs EUC (text message photograph requests, follow-up activity reminders, and corrective feedback only for predefined critical errors). In phase 2, participants exposed to TCBD/ABCB but who were nonadherent at 6 months received high-intensity (second remote MI session plus extra text messages) or low-intensity (mHealth alone) interventions.
Main Outcome And Measures:
The primary outcome was guideline adherence, a dichotomous measure of all 3 criteria: (1) appropriate CRS, (2) back seat location, and (3) never unrestrained. Outcomes were assessed at 6 and 12 months using logistic regression with prevalence differences, adjusted for randomization strata, caregiver gender, race, and ethnicity.
Results:
In phase 1, there were 474 participants (mean [SD] caregiver age, 36.1 [6.2] years; 443 mothers [93.5%]; 52 [11.0%] preferred Spanish]) of whom 342 were randomized to basic TCBD/ABCB and 132 to EUC. Among participants with 6-month follow-up data, 131 of 278 caregivers receiving TCBD/ABCB (47.1%; 95% CI, 41.3% to 53.0%) vs 38 of 118 receiving EUC (32.2%; 95% CI, 23.8% to 40.6%) were guideline adherent (absolute change in treatment response, 13.1%; 95% CI, 3.6% to 22.6%; P = .007) with 12-month maintenance effects (adjusted prevalence difference, 39.2%; 95% CI, 26.5% to 51.9%; P < .001). In phase 2, 185 participants who received TCBD/ABCB and were not guideline adherent were rerandomized to high-intensity (87 participants) or low-intensity (84 participants) intervention. High-intensity TCBD/ABCB had no effect compared with low-intensity TCBD/ABCB (adjusted prevalence difference, -3.9%; 95% CI -17.9% to 10.1%; P = .59).
Conclusions And Relevance:
In this randomized clinical trial of caregivers, TCBD/ABCB was associated with improved adherence to child passenger safety guidelines with lasting effects among those caregivers who were adherent at 6 months. These findings suggest that this remote precision prevention intervention against a leading cause of death may be adaptable to other settings.
Trial Registration:
ClinicalTrials.gov Identifier: NCT04238247.
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