Programs for Increasing Child Restraint and Booster Seat Use

Abundant research has shown that correctly using an appropriate child restraint or seat belt is the single most effective way to save lives and reduce injuries in crashes. However, unrestrained children continue to be overrepresented in motor vehicle fatalities, which indicates that additional lives can be saved by further increasing restraint use among children (Sauber-Schatz et al., 2014).

According to the 2021 National Survey of the Use of Booster Seats (NSUBS), 0% of children under age 1, 6.3% of children 1 to 3, 10.6% of children 4 to 7, and 13.2% of children 8 to 12 were observed to be unrestrained (Boyle, 2023).

Compared to the 2019 NSUBS, child restraint use in various age groups is either unchanged or slightly higher. In 2021 some 17.7% of children 1 to 3 were rear-facing, essentially unchanged from the 17.4% in 2019. The overall percentage of children 4 to 7 riding in car seats or booster seats increased from 2017 (73.2% versus 69.5% in 2019) with more kids in this age group riding in car seats over booster seats (42.2% in car seats in 2019 versus 32.5% in 2019) (Boyle, 2023).

Use:

Programs and campaigns aimed at increasing child restraint and booster seat use are likely common, but no summary is available.

Effectiveness:

While specific programs are discussed below, overall, the effectiveness of individual programs varies depending on program components, how the program is delivered, and how effectiveness is measured. Several recent systematic reviews summarized the research on interventions aimed at increasing child restraint use and found mixed results (Glerum et al., 2019; O’Toole & Christie, 2019; Sartin et al., 2019).

Programs that aim to increase knowledge or affect self-reported behaviors have shown some success; however, observed child restraint use is not often measured, so it is difficult to determine whether these programs increase child restraint use (Gielen et al., 2018; Glerum et al., 2019; Perez et al., 2020; Sartin et al., 2019). Simply increasing knowledge rarely leads to behavior change (see the Introduction), and research has shown knowledge about car seats to be a poor predictor of installation ability in a study of caregivers of children from birth to 3 who participated in an educational program (Kuroiwa et al., 2018).

Additionally, social desirability bias—that is, the tendency for people to give answers they think will be viewed favorably—makes it difficult to determine if self-reported restraint use behaviors are an accurate reflection of actual restraint use. For example, Perez et al. (2020) found that although 95% of caregivers reported their child was using a child restraint on every trip, 16% of children did not have one in the vehicle when a researcher conducted a check in the parking lot.

Several studies have demonstrated success in increasing observed restraint use. Will et al. (2009) used a message aimed at increasing caregivers’ perception of risk and combating barriers to correct restraint use to increase booster seat use among attendees of two large daycare/after-school programs in Eastern Virginia. The intervention included a video made with images to invoke emotions, crash test footage, well-respected experts, and personal stories to convey a message of high-threat consequences without using graphic, “gory” images. The study found significant increases in overall observed restraint use and booster seat use following exposure to the intervention and concluded that applying messages that increase perception of vulnerability using high-threat consequences (without gore) is a promising approach to increase booster seat use. Bryant-Stevens et al. (2013) used a similar approach with a research-based video that shared personal stories of a child’s injury and how that injury could have been prevented with a booster seat. Additionally, the program included educational sessions and distribution of booster seats to families in need. A significant increase in observed booster seat use was seen in the intervention community.

One of the issues identified when CPS laws were first being considered was the costs associated with obtaining child restraints. Because of this, many State and local organizations initiated programs to make child restraints available at low or no cost to parents through child restraint loan or rental programs (Zaza et al., 2001). Early research found that distribution programs coupled with educational messaging were effective (Ehiri et al., 2006; Louis & Lewis, 1997; Zaza et al., 2001). However, these studies were conducted when both CPS laws and availability and acceptance of child restraints were different than seen today, and more recent research has shown mixed results (Glerum et al., 2018).

As using child restraints has become the norm and child restraints themselves have become more readily available, use of these programs has decreased significantly. However, distribution programs may still have an impact on child restraint use in populations where child restraint use is low. A study by CDC found that child safety seat distributions—in combination with other evidence-based practices—may have contributed to significant increases in proper child restraint use in five American Indian/Alaskan Native tribal communities (Billie et al., 2016; West & Naumann, 2014). From 2010 to 2014 all five communities conducted distribution of child safety seats along with educational programs and enhanced enforcement practices. All communities reported increases in observed use of child safety seats (ranging from 6% to 40%) with the largest increases in communities with lower restraint use rates.

The “Strike Out Child Passenger Injury” program used community sports programs to promote booster seat use among 4- to 7-year-olds in 20 rural communities across 4 States – Alabama, Arkansas, Illinois, and Indiana (Aitken et al., 2013). In the intervention communities, information about proper restraint use was shared in conjunction with T-ball season. In addition to information, parents were given the opportunity to meet with a CPS technician during a T-ball event to get a personal assessment and recommendation for proper restraint use. Child restraints and booster seats were provided to families in need and baseball-themed prizes were provided to participants. Control communities received only an informational brochure. Following the short program, proper restraint use increased in intervention communities in 3 of 4 States. This study demonstrated that tailoring a program to fit in an established community event can have a short-term impact on restraint use in a rural community where resources are limited.

Cost:

Costs vary depending on program components and delivery.

Time to implement:

A good educational campaign or program will require 4 to 6 months to plan and implement.