Reviews of evidence regarding interventions to increase use of child safety seats

doi:10.1016/S0749-3797(01)00377-4

American Journal of Preventive Medicine

Volume 21, Issue 4, Supplement 1, November 2001, Pages 31-47

https://doi.org/10.1016/S0749-3797(01)00377-4 Get rights and content

Abstract

Background: In 1998, nearly 600 child occupants of motor vehicles aged younger than 4 years died in motor vehicle crashes. Yet approximately 29% of children aged 4 years and younger do not ride in appropriate child safety seat restraints, which, when correctly installed and used, reduce the need for hospitalization in this age group by 69% and the risk of death by approximately 70% for infants and by 47% to 54% for toddlers (aged 1 to 4 years).

Methods: The systematic review development team reviewed the scientific evidence of effectiveness for five interventions to increase child safety seat use. For each intervention, changes in the use of child safety seats or injury rates were the outcome measures evaluated to determine the success of the intervention. Database searching was concluded in March 1998. More than 3500 citations were screened; of these citations, 72 met the inclusion criteria for the reviews.

Results: The systematic review process identified strong evidence of effectiveness for child safety seat laws and distribution plus education programs. In addition, community-wide information plus enhanced enforcement campaigns and incentive plus education programs had sufficient evidence of effectiveness. Insufficient evidence was identified for education-only programs aimed at parents, young children, healthcare professionals, or law enforcement personnel.

Conclusions: Evidence is available about the effectiveness of four of the five interventions we reviewed. This scientific evidence, along with the accompanying recommendations of the Task Force elsewhere in this supplement, can be a powerful tool for securing the resources and commitment required to implement these strategies.

Introduction

M otor vehicle crash-related injuries kill more children than any other single cause in the United States.1 In 1998, a total of 1765 child occupants aged 14 years and younger died in motor vehicle crashes; of those, 33% were children younger than 4 years.1 In 1999, an estimated 272,000 motor vehicle occupants aged 14 and younger were injured in crashes.2

For children aged birth to 4 years, child safety seats can be extremely effective. When correctly installed and used, child safety seats reduce the need for hospitalization in this age group by 69%3 and the risk of death by approximately 70% for infants and by 47% to 54% for toddlers (aged 1 to 4 years).4 If all child passengers aged 4 years and younger were restrained, each year an additional 162 lives could be saved and 20,000 injuries could be prevented.5, 6

Approximately 29% of children aged 4 years and younger do not ride in appropriate restraints, placing them at twice the risk of fatal and nonfatal injuries of those riding restrained.2, 7, 8 In addition, approximately 85% of children riding in child safety seats are improperly restrained.9 Seating position imposes an additional risk factor: In passenger vehicles, children aged 12 years and younger are 36% less likely to die in a crash if seated in the back seat.10

Some groups of children are more at risk than others. Child safety seat use is lower among rural populations and low-income families.8, 11, 12, 13 Lack of access to affordable child safety seats might contribute to lower usage rates among low-income families. However, when they do own a safety seat, 95% of low-income families use it,5, 14, 15, 16 suggesting that strategies to increase the availability of free or low-cost child safety seats might be effective.

Given the high burden of fatal and nonfatal injury imposed on children by motor vehicle crashes, the effectiveness of child safety seats in reducing those injuries, and the continued low rate of correct use of child safety seats, we sought to identify which population-based interventions among those currently in use or contemplated by the public health community are most effective. As part of the Guide to Community Preventive Services (the Community Guide), we conducted systematic literature reviews to determine the effectiveness of population-based interventions to improve the use of child safety seats among children aged birth to 4 years.17, 18, 19

Section snippets

Methods

The general methods for conducting systematic reviews for the Community Guide have been described in detail elsewhere.17, 20, 21 The specific methods for conducting reviews of interventions to reduce motor vehicle occupant injuries are also described in detail elsewhere in this issue.18 This section briefly describes the specific methods to define the conceptual approach, search strategy, intervention selection, and outcome determination for interventions to improve the use of child safety

Child safety seat laws

Child safety seat laws require children traveling in motor vehicles to be restrained in federally approved safety seats appropriate for the child’s age and size. Legislation also specifies the children to whom the law applies by age, height, weight, or a combination of these factors.

Although all states currently have child safety seat laws, a better understanding of the evidence about the effectiveness of these laws will help policymakers in their efforts to strengthen these regulations. In

Incentive and education programs

Incentive and education programs reward parents for obtaining and correctly using child safety seats or directly reward children for correctly using safety seats. These programs include educational components of varying intensity. If incentives and education programs are effective in increasing use in the short-term, they might also provide the impetus for some parents to continue using safety seats beyond the program.

Education-only programs

Education-only programs provide information about the use of child safety seats and relevant skills to parents, children, or professional groups. Giving information to people provides the basic foundation for moving them toward behavior change such as performing new skills (e.g., routinely restraining children in safety seats) and enacting new policies (e.g., implementing hospital policies to discharge infants only if the parent uses a child safety seat). Provision of information is a central

Effectiveness

For all five interventions, the team identified key research issues that had not been answered in the systematic review process. These research issues were grouped by the types of evidence sought. The team identified sufficient or strong evidence of effectiveness for four interventions (i.e., child safety seat laws, community-wide information and enhanced enforcement campaigns, distribution programs, and incentive programs). However, several important research issues about the effectiveness of

Discussion

Systematic literature reviews are particularly useful for creating guidelines. The Task Force on Community Preventive Services (the Task Force) has done this by using the evidence from these systematic reviews to make recommendations about the use of the interventions.97 Systematic reviews are also useful for identifying gaps in our knowledge base. The research questions provided in this article should be used to guide future research, both by government agencies and foundations in allocating

Acknowledgements

We thank the following individuals for their contributions to this review: Erin Finley and Krista Hopkins, Research Assistants; Randy Elder, Service Fellow; Vilma G. Carande-Kulis and Mary Olufemi Alao, Economics Team; Sandra Bonzo and Joanna Taliano, Research Librarians; Kate W. Harris, Editor; our Consultation Team—J. C. Bolen, PhD, MPH, National Center for Chronic Disease Prevention and Health Promotion, CDC, Atlanta, GA; R. D. Brewer, MD, MSPH, Nebraska Department of Health, Lincoln; S. D.

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Urban and Rural Child Deaths from Motor Vehicle Crashes: United States, 2015-2019
2022, Journal of Pediatrics
The objective of the study was to examine child deaths in motor vehicle crashes by rurality, restraint use, and state child passenger restraint laws.
2015-2019 Fatality Analysis Reporting System data were analyzed to determine deaths and rates by passenger and crash characteristics. Optimal restraint use was defined using age and the type of the restraint according to child passenger safety recommendations.
Death rates per 100 000 population were highest for non-Hispanic Black (1.96; [1.84, 2.07]) and American Indian or Alaska Native children (2.67; [2.14, 3.20]) and lowest for Asian or Pacific Islander children (0.57; [0.47, 0.67]). Death rates increased with rurality with the lowest rate (0.88; [0.84, 0.92]) in the most urban counties and the highest rate (4.47; [3.88, 5.06]) in the most rural counties. Children who were not optimally restrained had higher deaths rates than optimally restrained children (0.84; [0.81, 0.87] vs 0.44; [0.42, 0.46], respectively). The death rate was higher in counties where states only required child passenger restraint use for passengers aged ≤6 years (1.64; [1.50, 1.78]) than that in those requiring child passenger restraint use for passengers aged ≤7 or ≤8 years (1.06; [1.01, 1.12]).
Proper restraint use and extending the ages covered by child passenger restraint laws reduce the risk for child crash deaths. Additionally, racial and geographic disparities in crash deaths were identified, especially among Black and Hispanic children in rural areas. Decision makers can consider extending the ages covered by child passenger restraint laws until at least age 9 to increase proper child restraint use and reduce crash injuries and deaths.
Improper Restraint Use in Pediatric Patients Involved in Motor Vehicle Collisions
2022, Journal of Surgical Research
Motor vehicle collisions (MVCs) are the leading cause of unintentional death among children and adolescents; however, public awareness and use of appropriate restraint recommendations are perceived as deficient. We aimed to investigate the use of child safety restraints and examine outcomes in our community.
We retrospectively queried a level 1 trauma registry for pediatric (0-18 y) MVC patients from October 2013 to December 2018. Demographic and clinical variables were recorded. Data regarding appropriate restraint use by age group were examined.
Four hundred thirty-four cases of pediatric MVC were identified. Overall, 53% were improperly restrained or unrestrained. Sixty-two percent of car seat age and 51% of booster age children were improperly restrained or unrestrained altogether. Fifty-nine percent of back seat riding, seatbelt age were improperly restrained/unrestrained, with 26% riding in the front. Fifty-one percent of seatbelt-only adolescents were not belted. Black, non-Hispanic children were more often improperly restrained/unrestrained compared to Hispanics (63% versus 48%, P = 0.001). Improperly restrained/unrestrained children had higher injury severity (10% versus 4% Injury Severity Score > 25, P = 0.021), require operative/interventional radiology (33% versus 19%, P = 0.001), and be discharged to rehabilitation or skilled nursing facility (5.2% versus 1.5%, P = 0.033). Mortality in adolescents was higher among those unrestrained (5.2% versus 0.8%, P = 0.034).
Although efforts to improve adherence to restraint regulations have greatly increased in the last decade, more than half of children in MVC are still improperly restrained. Injury prevention services and community outreach is essential to educate the most vulnerable populations, especially those with infants and toddlers, on adequate motor vehicle safety measures in our community.
Use of child safety seats and booster seats in the United States: A comparison of parent/caregiver-reported and observed use estimates
2021, Journal of Safety Research
Background: Motor-vehicles crashes are a leading cause of death among children. Age- and size-appropriate restraint use can prevent crash injuries and deaths among children. Strategies to increase child restraint use should be informed by reliable estimates of restraint use practices. Objective: Compare parent/caregiver-reported and observed child restraint use estimates from the FallStyles and Estilos surveys with the National Survey of the Use of Booster Seats (NSUBS). Methods: Estimates of child restraint use from two online, cross-sectional surveys—FallStyles, a survey of U.S. adults, and Estilos, a survey of U.S. Hispanic adults—were compared with observed data collected in NSUBS. Parents/caregivers of children aged ≤ 12 years were asked about the child’s restraint use behaviors in FallStyles and Estilos, while restraint use was observed in NSUBS. Age-appropriate restraint use was defined as rear-facing child safety seat (CSS) use for children aged 0–4 years, forward-facing CSS use for children aged 2–7 years, booster seat use for children aged 5–12 years, and seat belt use for children aged 9–12 years. Age-appropriate restraint users are described by demographic characteristics and seat row, with weighted prevalence and corresponding 95% confidence intervals (CI) calculated. Results: Overall, child restraint use as reported by parents/caregivers was 90.8% (CI: 87.5–94.1) (FallStyles) and 89.4% (CI: 85.5–93.4) for observed use (NSUBS). Among Hispanic children, reported restraint use was 82.6% (CI: 73.9–91.3) (Estilos) and 84.4% (CI: 79.0–88.6) for observed use (NSUBS, Hispanic children only). For age-appropriate restraint use, estimates ranged from 74.3% (CI: 69.7–79.0) (FallStyles) to 59.7% (CI: 55.0–64.4) (NSUBS), and for Hispanic children, from 71.5% (CI: 62.1–81.0) (Estilos) to 57.2% (CI: 51.2–63.2) (NSUBS, Hispanic children only). Conclusion and Practical Application: Overall estimates of parent/caregiver-reported and observed child restraint use were similar. However, for age-appropriate restraint use, reported use was higher than observed use for most age groups.
Unintentional injury deaths in children and youth, 2010–2019
2021, Journal of Safety Research
Background: Unintentional injuries are the leading cause of death for children and youth aged 1–19 in the United States. The purpose of this report is to describe how unintentional injury death rates among children and youth aged 0–19 years have changed during 2010–2019. Method: CDC analyzed 2010–2019 data from the National Vital Statistics System (NVSS) to determine two-year average annual number and rate of unintentional injury deaths for children and youth aged 0–19 years by sex, age group, race/ethnicity, mechanism, county urbanization level, and state. Results: From 2010–2011 to 2018–2019, unintentional injury death rates decreased 11% overall—representing over 1,100 fewer annual deaths. However, rates increased among some groups—including an increase in deaths due to suffocation among infants (20%) and increases in motor-vehicle traffic deaths among Black children (9%) and poisoning deaths among Black (37%) and Hispanic (50%) children. In 2018–2019, rates were higher for males than females (11.3 vs. 6.6 per 100,000 population), children aged < 1 and 15–19 years (31.9 and 16.8 per 100,000) than other age groups, among American Indian or Alaska Native (AIAN) and Blacks than Whites (19.4 and 12.4 vs. 9.0 per 100,000), motor-vehicle traffic (MVT) than other causes of injury (4.0 per 100,000), and rates increased as rurality increased (6.8 most urban [large central metro] vs. 17.8 most rural [non-core/non-metro] per 100,000). From 2010–2011 to 2018–2019, 49 states plus DC had stable or decreasing unintentional injury death rates; death rates increased only in California (8%)—driven by poisoning deaths. Conclusion and Practical Application: While the overall injury death rates improved, certain subgroups and their caregivers can benefit from focused prevention strategies, including infants and Black, Hispanic, and AIAN children. Focusing effective strategies to reduce suffocation, MVT, and poisoning deaths among those at disproportionate risk could further reduce unintentional injury deaths among children and youth in the next decade.
Child restraint system use and its associated factors in Shenzhen
2021, Accident Analysis and Prevention
Child restraint system (CRS) is effective to protect child passenger safety in a motor vehicle crash. However, research on CRS is limited and the use rate of CRS is not high in China. We carried out a cross-sectional study to examine the use of CRS and its associated factors in Shenzhen. Via the method of cluster random sampling, parents who had at least one child aged 0 to 6 and owned a car from nine community health service centers and eight kindergartens were invited to complete the self-administered questionnaire during April and May 2014, including their knowledge of, attitude toward, and use behavior of CRS and socio-demographics. Multivariable logistic regression was used to explore the factors associated with CRS use. A total of 3768 parents participated in the survey, with a mean age of 33.94. Parents’ knowledge and attitude regarding CRS were fair, with the mean score of 3.07 and 3.33 out of 6, respectively, and only 22.8% of them used CRS for their child passengers. Children aged below 3 years, drivers owing expensive cars and wearing seatbelts, and parents with higher knowledge and attitude scores had greater likelihoods to use CRS. Moreover, trip frequency and distance were also significantly associated with CRS use. The findings indicate that the use rate of CRS is low in Shenzhen and parents have fair levels of knowledge and attitude regarding CRS use. Comprehensive public education programs and legislative interventions are urgently required to increase the use of CRS and ensure child passenger safety in Shenzhen
Assessing an App-Based Child Restraint System Use Intervention in China: An RCT
2020, American Journal of Preventive Medicine
While child restraint systems are effective in protecting children from crash-related injuries and deaths, their use in China is extremely low. This study assessed the effectiveness of child restraint system education with and without behavioral skills training on improved use and explored participants’ views regarding content and delivery of an onsite intervention and online (WeChat) boosters.
A randomized trial was conducted in 6 kindergartens from May 2017 to January 2018 in Shantou and Chaozhou, China. Selected kindergartens were randomly assigned to 3 groups: (1) control, (2) child restraint system education‒only, and (3) child restraint system education plus behavioral skills training. Analysis was conducted in May 2018.
Participants were parents from the selected kindergartens.
Both intervention groups received child restraint system education that included one-time onsite education and biweekly online boosters for 3 months using an app to deliver education messages.
Survey questions included parent knowledge, attitude and behaviors of child restraint system use, and opinions related to the content and delivery of the onsite intervention and online boosters.
Child restraint system use in both intervention groups was higher than that of the control group post-intervention (27.3% and 31.7%, respectively). Compared with the control group, the intervention groups had a higher percentage of correct answers to all 9 items, except Item 7 measuring the parents’ knowledge, attitude, and behaviors of child passenger safety after the intervention. Lower parent's level of education (OR=7.00, 95% CI=2.62, 18.70) and older child age (4 years: OR=3.92, 95% CI=1.08, 5.28; 5 years: OR=2.08, 95% CI=1.52, 5.31) were associated with lower rates of child restraint system use. Most parents (92.3%) preferred the online over the onsite intervention component.
An education intervention was effective in improving parents’ knowledge, attitude, and practice of child restraint system use. A social media intervention booster (WeChat) may provide a new channel to help promote child passenger safety in China.

View all citing articles on Scopus

¹: The names and affiliations of the Task Force members are listed in the front of this supplement and at www.thecommunityguide.org.

View full text

Reviews of evidence regarding interventions to increase use of child safety seats

Abstract

Introduction

Section snippets

Methods

Child safety seat laws

Incentive and education programs

Education-only programs

Effectiveness

Discussion

Acknowledgements

Am J Prev Med

Am J Prev Med

Am J Prev Med

Am J Prev Med

Am J Prev Med

Accid Anal Prev

J Safety Res

Accid Anal Prev

Accid Anal Prev

Patient Educ Couns

Patient Educ Couns

Patient Educ Couns

J Safety Res

Am J Prev Med

1998 mortality data

Research noterevised estimates of child restraint effectiveness

Childhood injurycost & prevention facts

Child safety seatshow large are the benefits and who should pay?

Air-bag associated fatal injuries to infants and children riding in front passenger seats-United States

MMWR

Children in car crashesanalysis of data for injury and use of restraints

Pediatrics

Child passengers at risk in Americaa national study of car seat misuse

Children’s traffic safety programinfluence of early elementary school safety education on family seat belt use

J Trauma

National Occupant Protection Use Surveycontrolled intersection study Research note

Evaluation of an infant car seat program in a low-income community

Am J Dis Child

Increasing car seat use for toddlers from inner-city families

Am J Public Health

Strategies to increase the use of child safety seats by low-income familiesa report to the Committees on Appropriations, U.S. House of Representatives, U.S. Senate

Patterns of automotive safety restraint use in Rhode Islandimpact of the child passenger restraint law

R I Med J

Effects of legislation on motor vehicle injuries to children

Am J Dis Child

An estimate of the lifesaving benefit of child restraint use legislation

J Health Econ

An assessment of the California child passenger restraint requirement

Am J Public Health

Is the Oklahoma child restraint law effective?

Am J Public Health

The Tennessee child restraint law in its third year

Am J Public Health

The effectiveness of legislation, education, and loaners for child safety in automobiles

J Community Psychol

The effects of a mandatory child restraint law on injuries requiring hospitalization

Am J Dis Child

Experimental evaluation of public policythe case of state legislation for child passenger safety

J Appl Behav Anal

Child restraint law effects on motor vehicle accident fatalities and injuriesthe New Mexico experience

Pediatrics

Effects of child restraint laws on traffic fatalities in eleven states

J Trauma

Evaluation of the Rhode Island child restraint law

Am J Public Health