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ABBREVIATIONS. IHS, Indian Health Service; TBA-LC, Tse'Bit' 'Ai Learning Center.

Injuries are the leading cause of death for Native Americans from age 1 to 44 years, accounting for 63% of all deaths in that age range.[1] Motor vehicles are responsible for 55% of all Native American injury deaths.[2] Among Native American children 1 to 14 years of age, the death rate from motor-vehicle occupant injuries (6.9/100 000 per year) is more than double that of white children in the United States (3.3/100 000 per year).[3]

To help reduce this toll, both the Indian Health Service (IHS) and individual tribes have initiated car seat loaner programs. Because of widespread poverty--the unemployment rate is as high as 80% in some Native American communities--no fees or deposits are collected in many of these programs. The lack of a financial incentive, geographic isolation, and other factors often mean that loaned car seats are not returned when infants outgrow them. To address this problem, an innovative program was launched by the Shiprock Service Unit on the Navajo Nation. The program involves recycling loaned car seats through a "cottage industry" based in a learning center for developmentally disabled children and youth.

The state of New Mexico has had a child restraint law since 1983,[4] and the Navajo Nation since 1988. The official policy of the Navajo Area IHS is to discharge every infant born at an IHS hospital in an approved car seat. A car seat loaner program at the Shiprock Hospital, a 50-bed facility run by the IHS, was established in 1986. The Navajo Nation also has a loaner program that circulates infant car seats without charge through participating chapter houses.

The Tse'Bit' 'Ai Learning Center (TBA-LC) serves Navajo children aged 3 to 21 years with developmental disabilities. In addition to teaching academic skills, the program emphasizes self-help, independent living, and personal/social skills. A major goal of the TBA-LC is to prepare students for placement in a structured academic program or vocational/ sheltered workshop setting. However, until the car seat recycling program, no work opportunities were available to the students.

The car seat recycling program involves a collaboration among the Navajo Nation, IHS, Bureau of Indian Affairs, and the TBA-LC. Individual work stations were built so that students would have their own brushes, sponges, and abrasive pads. A single recycling operation--dismantle the seats, scrub the shells or liners, reassemble the clean seats--is performed during each work session. The students watch videotapes about child passenger safety, so they learn about the meaning and importance of their work.

Students learn to use a time clock to keep track of their work hours. The dormitory teacher also documents their hours on time sheets. For their work, the students receive $1 an hour, which they can use for savings or weekly shopping trips. The TBA-LC receives from the IHS $5 per recycled car seat or about $150 per month. All of the funds from IHS are used for student wages. Rather than representing a new appropriation, the funding comes from the IHS injury prevention program budget. The rationale is simple: just as IHS automobiles need to be maintained, so do IHS car seats.

Because TBA-LC is across the street from the Shiprock Hospital, transfer of seats between the hospital loaner program and the recycling program is very convenient. Parents can return seats to the hospital during well-child visits, or IHS public health nurses and Navajo Community Health Representatives can pick up unused seats during their home visits. The Shiprock Service Unit also initiated a mass media car seat return campaign. Three radio stations broadcast public service announcements in Navajo and English. A local fast-food restaurant donated 1000 coupons, each good for a free meal to parents who returned their car seats.

Families are strongly encouraged to buy a car seat during pregnancy; only those without a safety seat at the time of discharge are loaned one at the hospital. Car seat education is done in the mother's hospital room with her infant. Staff from the Navajo Nation Health Education Division, and from IHS Dental and Environmental Health Divisions, share the teaching responsibilities on a rotating basis. A medical clerk records the car seat information in the infant's chart and on a separate program card. Parents are expected to purchase their own car seat-and return the loaner--by the time their child is 4 months old.

The Shiprock Hospital has about 100 births per month and loans about 30 car seats each month. Six months after the recycling program began, an average of 30 car seats have been returned per month. Encouraged by the responses, the Navajo Nation--which circulates more than 1800 car seats--has begun sending their returned seats to the TBA-LC for recycling.

The car seat program is very popular with the students at TBA-LC. They enjoy the comraderie--and water play--involved in recycling the seats, and they feel that they are contributing to the safety of other Navajo children. For the first time, they have money to spend during field trips and visits to local markets. The TBA-LC staff also is pleased with the program. They are proud to be teaching work and money-handling skills. Because the students enjoy the work program so much, work privileges have become part of a behavior modification approach, used as an incentive to good behavior. The IHS also benefits: the agency can now pay $5 for a recycled car seat, rather than $30 to $50 for a new one. Public health nurses and community health representatives have renewed enthusiasm for recovering loaned car seats. Families are more likely to return the loaned car seats knowing that the TBA-LC students will be recycling them.

Because of social, cultural, and economic factors, programs for children with disabilities have often been incomplete and poorly coordinated.[5] An unanticipated positive outcome of the program is the increased awareness of the needs of individuals with developmental disabilities on the Navajo Nation. Another reward of the recycling program is the enhanced collaboration and mutual respect among IHS and tribal staff--health educators, nurses, Community Health Representatives, environmental sanitarians, TBA-LC workers--who often are separated by agency and other barriers.

To our knowledge, this is the first program to incorporate car seat recycling as a work component for developmentally disabled youth. The funding agency (IHS), the staff and students at the TBA-LC, and the personnel involved in the car seat loaner program have directly benefited. Concerns about legal liability have been addressed in a comprehensive manner, by providing detailed education for staff and parents, having parents sign a waiver, closely inspecting seats for missing parts or damage, and retiring car seats that have been recalled or involved in a car crash.[6]

TBA-LC hopes to expand the work program by making cloth car seat inserts. Manufactured by the students, the inserts with traditional Navajo designs could be distributed nationally. The recycling program would also expand greatly if IHS or the Navajo Nation embarked on a more intensive car seat loaner program for older children. Currently, few toddler or convertible car seats are available to loan to families.

The recycling program is a model that can be adopted in many other communities. Trained instructors, attention to liability issues, a secure funding source, and an appropriate work-space are prerequisites for replicating the program. In addition to agencies serving people with disabilities, car seat recycling programs could be undertaken by scouting groups, inner city boys' or girls' clubs, or similar groups that wish to combine a fund-raising opportunity with a meaningful contribution to child passenger safety

ACKNOWLEDGMENTS

This work was supported, in part, by project MCH 354001-02-1 from the EMS for Children Program, Health Resources and Services Administration, Department of Health and Human Services.

The opinions expressed in this paper are those of the authors and do not necessarily reflect the views of the Indian Health Service.

We are grateful to Frank Todacheeny, Annie Beasley, and the staff at the Shiprock Learning Center; Charles Dowell, PE, Pat Bohan, MPH, Nancy Bill, MPH, and Christine Benally-Speck, Phd, of the Navajo Area Indian Health Service; Marilyn Dawes at the Shiprock Hospital; and the Community Health Representatives and public health nurses of the Shiprock Service Unit.

Lawrence R. Berger, MD, MPH

Lovelace Medical Foundation

Albuquerque, NM

Lorraine M. Benally, CEHT

William Robson, RS, MS

Office of Environmental Health and Engineering

Navajo Area Indian Health Service

Shiprock, NM

Lenora M. Olson, MA

Dept of Emergency Medicine

University of New Mexico School of Medicine

Albuquerque, NM