ABSTRACT
Motor vehicle crashes are the most common cause of the mortality in the pediatric population. Preventive strategies are the best approach to reduce mortality and morbidity due to motor vehicle crashes. Since parents mostly refer to them for guidance, doctors should have a high level of knowledge and awareness to increase the usage of car safety seats. We thought that providing care for trauma patients could have a positive effect on the physicians’ awareness and knowledge level. Based on this, we aimed to assess the awareness and knowledge of pediatricians and emergency physicians and trauma doctors.
An electronic survey consisting of 23 questions was prepared. Demographic features, awareness and knowledge level of the physicians were assessed on three sections. Five suggestions in the guideline of the American Academy of Pediatrics were used to assess physicians’ knowledge level. The respondents were grouped as those providing clinical care for trauma patients and those do not.
The questionnaires were sent to 641 physicians and 323 who completed the questionnaire were included in the study. One hundred and fourteen (35.3%) of the respondents were providing clinical care for trauma patients. One hundred ninety (59.2%) respondents had children. Majority of the physicians had a satisfactory level of knowledge about car safety seat (CSS). The number of respondents reported having adequate self-awareness was found statistically significantly higher in the groups of doctors who have children and provide clinical care for trauma patients (p<0.01 and p=0.01, respectively). However, there was no significant difference in the level of knowledge between non-providers and providers of clinical trauma care (p>0.05). Interestingly, the knowledge level in physicians who had children was statistically significantly lower than in those with no children (p<0.01).
Our survey revealed that physicians who provide clinical care for trauma patients think they have a high level of knowledge about CSS. Unfortunately, their knowledge level was low as other physicians in the study group.
Keywords: Child, car safety seats, emergency medicine, motor vehicle, trauma
Introduction
Motor vehicle crashes (MVC) are the most common cause of pediatric mortality in developed countries. Preventive strategies are the best approach to reduce mortality and morbidity due to MVCs. Especially in children, increasing the proper use of child passenger restraints and car safety seats (CSS) is one of the key steps to reduce MVC-related deaths and injuries. The Center for Disease Control and Prevention (CDC) has reported that a 15% decrease in MVC-related deaths was achieved between 2007 and 2015.1 Unfortunately, in Turkey, awareness and knowledge of parents about CSS are very low.2,3 A few key elements are needed to increase the use of CSS such as making strict policies, laws and campaigns about the use of CSS and restraints, and increasing level of awareness pediatricians and parents. Although there are many studies in the literature focusing on parents’ awareness and knowledge, there is a limited number of studies about the knowledge of pediatricians.4-7 The study population in these studies was mostly office-based doctors and community pediatricians. However, emergency and intensive care doctors, who witness variety of injuries and even death due to MVCs, were included in a limited number of studies.8,9 We hypothesized that witnessing injuries due to MVCs may have a positive effect on the doctors’ knowledge and awareness. Therefore, we designed a questionnaire study to assess the level of self-reported awareness and knowledge of pediatricians and emergency physicians and trauma doctors.
Materials and Methods
A survey with a total of 23 questions was designed electronically. The survey comprised three different kinds of questions. The first section of the questionnaire targeted demographic data of physicians, while the second section targeted self-reported awareness of physicians, and the last section queried physicians’ knowledge about child passenger safety (including CSSs and booster seats) with 5 questions which were based on recommendations issued by the American Academy of Pediatrics (AAP) (Table 1).10 The questionnaire was sent to physicians via e-mail. Completion of the questionnaire form by responders was accepted as written consent. All completed surveys were included in this study and all incomplete surveys were excluded. Physicians were grouped according to whether they were involved in the care of trauma patients or not. Physicians’ knowledge was classified according to the number of correct answers (excellent: 5, very good: 4, satisfactory: 3, borderline: 2, and poor: 1 and 0 correct answers). Physicians’ awareness was classified as “excellent, very good, satisfactory, borderline and poor. This study was approved by the Dokuz Eylül University Medicine Clinical Research Ethics Committee (report number: 2274-GOA; 2015/21-07). No financial support was received for this study.
Statistical Analysis
Predictive Analytics Software version 23.0 (IBM Corp. Armonk, NY, USA) was used to analyze the data. The quantitative data were described as means and standard deviation. A chi-square test or Fisher’s exact test was used to compare the two groups of those who care for trauma patients or who do not. A p value of less than 0.05 was considered statistically significant.
Results
The questionnaire was sent to 641 physicians. 323 who completed surveys were included in this study. The male/female ratio was 1:1,8. The mean age of the participants was 34.07 (±6.20) years. Characteristic features of the physicians are summarized in Table 2. The self-reported awareness of CSS among the majority of physicians was satisfactory. The main source of knowledge about CSS was community forum web pages (32.9%). However, the percentage using the AAP policy statement on CSS as a source of information was 10.3%. Among physicians who had children, the use of the AAP as a knowledge source was significantly higher than in those who had no children (p<0.01). However, in the group who had children, the use of the AAP for the knowledge source was lower than (23%) the use of web forum pages (55%). To assess public awareness of CSS, the most frequent suggestion was advertising campaigns (76.4%). The other suggestions of the respondents are summarized in Table 3.
Among the participants, 191 (59.2%) respondents had children and 90.6% of them had children under 13 years old. The respondents who had children had a higher awareness level than who did not have children (p<0.001). Forty-one (21.4%) physicians had not used CSS and the main reason was that children refused to be seated in a CSS (24.3%). Eight (19.5%) physicians considered CSS unnecessary for their own children. Having a large family (14.6%) was another excuse in the study group. Seat belt (37.7%) was the most commonly used method to maintain safety of the children in the group who did not use CSS.
Five questions about CSS, which were suggested in the AAP guidelines, were directed to all respondents. The percentages of knowledge and awareness levels of all respondents and comparisons of knowledge and self-reported awareness levels of the groups are summarized in Table 4. Respondents who had children, or who provided clinical care for trauma patients considered their knowledge level satisfactory and The number of respondents reported having adequate self-awareness was found statistically significantly higher in the groups of doctors who have children and provide clinical care for trauma patients (p<0.01 and p=0.01, respectively). However, there was no significant difference in the level of knowledge between non-providers and providers of clinical trauma care (p>0.05).
Interestingly, the knowledge level of physicians who had children was statistically significantly lower than the rest of the participants (p<0.01).
Discussion
According to the CDC reports, MVCs are still a leading cause of mortality, especially in the pediatric population.11 The most important development in decreasing mortality secondary to MVCs was widespread use of CSS. The reduced risk of death with CSS use in the pediatric population was expressly stated in previous reports.12,13 Increasing the use of CSS depends on the awareness of parents and also physicians. There are many studies in the literature that determined the awareness and knowledge of parents about CSS.2,3,14,15 The common result of these studies was that there was low utilization of CSS. Additionally, one of the striking results of previous studies is that doctors were the most common source of guidance for CSS.7,14,16 This data comes with questions; do doctors have satisfactory knowledge about CSS? Moreover, how often do doctors abide by the requirements of car safety for their own children? In the literature, there are few reports which assessed the knowledge of physicians about CSS.4-9,14,16
In our study, having children had a statistically significant effect on the doctors’ awareness level as expected and this was in concurrence with previous studies.6,7 Probably being a parent makes doctors more sensitive about protecting their children, and encourages them to seek information about CSS. Despite all, interestingly, physicians who had children had lower knowledge levels and that was statistically significant. We associated this result with the public web forum pages which were the most commonly used source as a reference guide instead of the AAP guidelines.
Our hypothesis originated from an old saying “example is better than precept”. We thought that trauma doctors would have high levels of knowledge but our results were not as expected. Our study revealed that doctors had low levels of knowledge about CSS which complies with previous studies. Additionally, many trauma doctors in our study considered their own knowledge satisfactory.
Morrongiello et al.17 defined the “teachable moment” which can sensitize parents in the moment after injury and can have a positive effect to ensure preventive strategies for own child. Previous studies8,9 w that this phenomenon had no effect on doctors contrary to the effect on parents. Moreover, they may be desensitized because of witnessing injuries repeatedly. At the teachable moment, providing suggestions about CSS may be more efficient for parents. Zonfrillo et al.8 reported that although patients have enough time to obtain information about CSS, emergency physicians could allocate only a limited time to give information to parents in emergency settings because of overcrowded emergency department (ED).8 Majority of the respondents in our study suggested that the use of visual media or advertising campaigns in public areas could be an effective method to increase public awareness. In their study, Gielen et al.18, reported that using a kiosk in crowded EDs is an effective method to give information to patients and the suggestions in our study support this result. One of the major suggestions in our study was making strict laws for CSS. As in the use of adult restraints, we know that strict laws can be a disincentive factor if they are strictly enforced and can reduce mortality due to MVC.11
Study Limitation
Our study has some limitations. The first limitation was the low response rate, thus, we could not generalize the results of this study to all physicians. Second, the study was based on the responses of doctors, but we could not assess their knowledge objectively. This could perhaps cause bias in our study results. In spite of overcrowding in EDs, we believe that EDs can be appropriate places to provide information about CSS either by physicians or through visual media. We advocate that making laws and policies about CSS is necessary and should be strictly enforced.
Conclusion
In conclusion, our survey revealed that physicians, who care for trauma patients, assume that they have high levels of knowledge about CSS. Unfortunately, their knowledge level was as low as in other physicians in the study group.
Ethics
Ethics Committee Approval: Dokuz Eylül University Medicine Clinical Research Ethics Committee (approval number: 2274-GOA; 2015/21-07).
Peer-review: Externally and internally peer-reviewed.
Authorship Contributions
Concept: A.Ç., E.U., A.E., M.D., H. Ç, Design: A.Ç., E.U., A.E., M.D., Data Collection or Processing: A.Ç., F.Ç.Ç., B.B., U.K., Analysis or Interpretation: A.Ç., U.K., D.Y., M.D., Literature Search: A.Ç., M.D., Writing: A.Ç.
Conflict of Interest: No conflict of interest was declared by the authors.
Financial Disclosure: The authors declared that this study received no financial support.
