Motor Vehicle Injury Child Safety Seats: Community-Wide Information and Enhanced Enforcement Campaigns

The CPSTF finding is based on evidence from a systematic review of 4 studies (search period through March 1998). The review was conducted on behalf of the CPST by scientists from CDC’s Division of Unintentional Injury Prevention with input from a team of specialists in systematic review methods and experts in research, practice and policy related to motor vehicle injury prevention.

Four studies qualified for the review.

• Child safety seat use: increased by a median of 12 percentage points (interquartile interval: 3.8 to 21 percentage points; 4 studies)

An economic review of this intervention was not conducted because the CPSTF did not have enough information to determine if the intervention works.

Results should be applicable to variety of settings and populations in the United States, including those of mixed socioeconomic status.

CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. (What are evidence gaps?)

The following outlines evidence gaps for reviews of these interventions to increase use of child safety seats: Laws Mandating Use; Community-Wide Information and Enhanced Enforcement Campaigns; Distribution and Education Programs; Incentive and Education Programs; Education Programs When Used Alone.

Results from the Community Guide review indicate 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). Insufficient evidence was found to determine the effectiveness of education programs alone for increasing child safety seat use. Several important research issues about the effectiveness of these interventions remain.

Does effectiveness of the intervention change when specific elements are changed? For example:

• Does the effectiveness of child safety seat laws vary depending on the requirements of different state laws?
• Does effectiveness of laws vary depending on the intensity and visibility of regular enforcement in the state?
• Would the threat of being charged with contributory negligence if an unrestrained child is killed or injured in a motor vehicle crash change the effectiveness of the law?
• What role does information about laws play in compliance rates?
• Are distribution programs sponsored by medical care organizations more or less effective than programs implemented by other organizations (e.g., insurance companies or community organizations)?
• Are low-cost rental programs any more or less effective than free loan programs?
• Are different incentives needed for different devices (e.g., infant safety seats, child seats, booster seats, safety belts)?
• What is the relative effectiveness of different incentives (e.g., direct rewards related to restraint use vs. chances to win prizes)?

What is the long-term effectiveness of each intervention? For example:

• How can the effectiveness of a child safety seat law be maintained over time?
• Can incentive programs improve long-term use of child safety seats? If so, what kind of reward schedule and distribution method is necessary to maintain positive effects?

How effective are various combinations of these four interventions? For example:

• Does enhanced enforcement provide marginal benefit to that provided by legislation?
• Do hospital discharge policies requiring that newborns be restrained in an approved device increase the effectiveness of distribution programs?
• Because the effectiveness of education alone has not been established, basic research questions remain. For example:
  • What amount and quality of content are necessary to improve knowledge, attitudes, and behaviors?
  • What are appropriate educational contents and methods for delivery to children at various developmental stages?
  • What are the appropriate outcomes to measure when educating young children about the use of child safety seats?
• Is education alone effective to:
  • Increase parental use of child safety seats?
  • Increase children’s independent use of child safety seats?
  • Increase enforcement of child safety seat laws by law enforcement officials?
  • Encourage hospital personnel to develop and enforce policies about child safety seat use?

Other Positive and Negative Effects

The studies included in the reviews did not measure other positive and negative effects of the interventions. For all five interventions, research is needed to determine whether each intervention is likely to either increase or reduce misuse of child safety seats. Research is also needed to determine the role of community-wide or individual education in facilitating the effectiveness of other interventions (e.g., legislation, loaner programs).

Applicability

Each of the effective interventions should be applicable in most of the relevant target populations and settings. However, differences in the effectiveness of each intervention for specific subgroups of the population could not be determined. Several questions about the applicability of these interventions in settings and populations other than those studied remain. For example:

• Are these interventions equally effective in all populations within a state (e.g., racial and ethnic minorities, high- and low-income populations, or behavior change-resistant populations)?
• How must the content and methods of the educational components of interventions be altered to work in different populations?
• Are these interventions effective in populations that already have high baseline safety seat use rates?
• Do programs targeted at parents of infants improve the rate at which parents buy or use child safety seats for children older than 1 year?
• Are incentive programs effective in settings other than those studied (e.g., state motor vehicle inspection stations) or when implemented by other organizations (e.g., community groups or local businesses)?

Economic Evaluations

The team did not identify any economic evaluation meeting Community Guide standards for these interventions. Thus, basic economic research must still be conducted:

• What is the cost of interventions to increase the use of child safety seats?
• Are interventions to increase the use of child safety seats cost-saving?
• What is the return on investment of interventions to increase child safety seat use?

• Included studies evaluated campaigns that provided information on the importance and correct use of child safety seats through paid advertisements, public service announcements, commentaries by community leaders on local television and radio programs, newspaper articles and editorials, displays of safety seats in public locations, and direct mailings.
  • In three studies conducted in states with existing child safety seat laws, the campaigns also incorporated special enforcement components, such as traffic checkpoints, assignment of law enforcement officers dedicated to enforcing the safety seat use law, and alternative penalties in place of citations (for example, informational warnings or vouchers to waive fines if a safety seat is purchased).
• Campaigns were conducted in cities, suburbs, and states in the U.S., Canada, and Australia and involved populations at all socioeconomic levels.
• Numerous community organizations and government agencies such as public safety and public health offices, schools, advocacy organizations, and parent groups worked together to design and implement the campaigns.
• Campaigns were directed at parents of children from birth to 11 years of age; none of the studies reported the racial or ethnic makeup of the study population.

Effectiveness Review

Analytic Framework see Figure 1 on page 32

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Effectiveness Review

Summary Evidence Table — Effectiveness Review

The number of studies and publications do not always correspond (e.g., a publication may include several studies or one study may be explained in several publications).

Effectiveness Review

Decina LE, Temple MG, Dorer HS. Increasing child safety-seat use and proper use among toddlers. Evaluation of an enforcement and education program. Accid Anal Prev 1994;26:667 73.

Heathington KW, Philpot JW, Perry RL. Impact of legislation and public information and education on child passenger safety. Transportation Res Rec 1982;62 70.

Lane JM, Milne PW, Wood HT. Evaluation of a successful rear seat belt publicity campaign. The 12th ARRB Conference, Hobart, Tasmania, August 27 31, 1984. pp. 13 21.

Pless IB, Stulginskas J, Zvagulis I. Observed effects of media campaigns on restraint use.Can J Public Health 1986;77:28 32.

The following outlines the search strategy used for reviews of these interventions to increase use of child safety seats: Laws Mandating Use; Community-Wide Information and Enhanced Enforcement Campaigns; Distribution and Education Programs; Incentive and Education Programs; Education Programs When Used Alone.

The reviews of interventions to reduce motor vehicle-related injury reflect systematic searches of multiple databases as well as reviews of reference lists and consultations with experts in the field. The team searched six computerized databases (MEDLINE, Embase, Psychlit, Sociological Abstracts, EI Compendex, and Transportation Research Information Services [TRIS]), which yielded 10,958 titles and abstracts for articles, book chapters, reports, and published papers from the Association for the Advancement of Automotive Medicine proceedings about safety belts, alcohol-impaired driving or child passenger safety. Studies were eligible for inclusion if:

• They were published from the originating date of the database through June 2000 (March 1998 for child safety seat interventions)
• They involved primary studies, not guidelines or reviews
• They were published in English
• They were relevant to the interventions selected for review
• The evaluation included a comparison to an unexposed or less-exposed population
• The evaluation measured outcomes defined by the analytic framework for the intervention

The search strategy specific to child passenger safety is not available.

The following considerations are drawn from studies included in the evidence review, the broader literature, and expert opinion.

• Community-wide information and enhanced enforcement campaigns can increase public awareness of child safety seat laws and support other child passenger safety interventions.
• Enhanced enforcement might increase detection and arrest for alcohol-impaired driving and other offenses.
• Potential barriers noted by the Task Force include the following:
  • Costs of developing and disseminating public information and educational material (including television and radio announcements)
  • Enlisting the support and cooperation of the media, police departments, and other community leaders
  • Training enforcement personnel about the importance of enforcing child-restraint device laws
  • Increased burden on court systems that handle additional offenders

Healthy People 2030

Healthy People 2030 includes the following objectives related to this CPSTF recommendation.

• Reduce emergency department visits for nonfatal unintentional injuries — IVP-04
• Reduce deaths from motor vehicle crashes — IVP-06
• Reduce the proportion of deaths of car passengers who weren’t buckled in — IVP-07