Motor Vehicle Injury Child Safety Seats: Distribution and Education Programs

Summary of CPSTF Finding

The Community Preventive Services Task Force (CPSTF) recommends interventions that use distribution and education programs to increase child safety seat use.


Programs provide parents and caregivers with approved child safety seats, either at no cost or through a loan or low-cost rental, and educate them about the importance of child passenger safety. Programs target families who are experiencing financial hardship or do not understand the importance of always using a safety seat.

CPSTF Finding and Rationale Statement

Read the CPSTF finding.

About The Systematic Review

The CPSTF finding is based on evidence from a systematic review of 10 studies (search period through March 1998).

The review was conducted on behalf of the CPSTF 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.

Summary of Results

More details about study results are available in the published evidence review.

The systematic review included 10 studies.

  • Proper use of child safety seats increased by a median of 23 percentage points (10 studies)
  • Possession of safety seats increased by a median of 51% (5 studies)

Summary of Economic Evidence

An economic review of this intervention did not find any relevant studies.


Results of this review should be applicable to families of any socioeconomic status and ethnic background across the United States. Evaluated programs were effective in a variety of urban, suburban, and rural settings.

Evidence Gaps

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?)

  • 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?
  • Do hospital discharge policies requiring that newborns be restrained in an approved device increase the effectiveness of distribution programs?
  • Do interventions increase or reduce misuse of child safety seats?
  • What is the role of community-wide or individual education in facilitating the effectiveness of other interventions distribution programs?
  • 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?
  • What is the cost of interventions?
  • Are interventions cost-saving?
  • What is the return on investment?

Study Characteristics

  • Included studies evaluated programs that provided free loaner child safety seats, low-cost rentals, or direct giveaways.
  • Programs gave parents information on how to use the seats correctly. This educational component varied considerably across programs in terms of content, length, intensity, and type of teaching method.
    • Some programs provided lectures, brochures, or pamphlets on how to use the safety seat. Other programs used more active educational and behavioral techniques, such as discussions, problem solving, demonstrations, or rehearsal of correct use.
  • Programs were implemented in hospitals, clinics, and homes and through insurance companies.
  • Programs primarily targeted parents of infants rather than older children.
  • Studies were conducted in the United States, Canada, Australia, and Sweden.


Zaza S, Sleet DA, Elder RW, Shults RA, Dellinger A, Thompson RS. Response to letter to the editor. American Journal of Preventive Medicine. 2002;22:330-1.

Sleet DA. Evidence based injury prevention: guidance for community action. In: Australian Third National Conference on Injury Prevention and Control. Australian Third National Conference on Injury Prevention and Control. Brisbane, Queensland, Australia; 1999.

Analytic Framework

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.

Summary Evidence Table

Effectiveness Review

Summary Evidence Table – See Appendix on pages 44-47

Included Studies

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

Christophersen ER, Sullivan MA. Increasing the protection of newborn infants in cars.Pediatrics 1982;70:21 5.

Colletti RB. Longitudinal evaluation of a statewide network of hospital programs to improve child passenger safety. Pediatrics 1986;77:523 9.

Culler CJ, Cunningham JL. Compliance with the child passenger protection law: effects of a loaner program for low-income mothers. Washington, DC: U.S. Department of Transportation, National Highway Traffic Safety Administration, 1980. DOT HS 805 801.

Geddis DC, Appleton IC. Establishment and evaluation of a pilot child car seat rental scheme in New Zealand. Pediatrics 1986;77:167 72.

Hletko PJ, Robin SS, Hletko JD, Stone M. Infant safety seat use: reaching the hard to reach. Am J Dis Child 1987;141:1301 4.

Lindqvist KS. Does the use of child safety seats increase as the result of loan schemes? Accid Anal Prev 1993;25:421 9.

Reisinger KS, Williams AF. Evaluation of programs designed to increase the protection of infants in cars. Pediatrics 1978;62:280 7.

Robitaille Y, Legault J, Abbey H, Pless IB. Evaluation of an infant car seat program in a low-income community. Am J Dis Child 1990;144:74 8.

Saalberg JH, Morrison AJ. Household survey. In: Evaluation of the League General Insurance Company child safety seat distribution program; DOT HS 806 253. Washington, DC: U.S. Department of Transportation, National Highway Traffic Safety Administration, 1982:63 120.

Saalberg JH, Morrison AJ. Restraint use and injury experience. In: Evaluation of the League General Insurance Company child safety seat distribution program; DOT HS 806 253. Washington, DC: U.S. Department of Transportation, National Highway Traffic Safety Administration, 1982:22 47.

Search Strategies

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.

Considerations for Implementation

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

  • Programs that lend or give away safety seats must use new seats, not refurbished ones. The safety of seats that have been involved in crashes and then refurbished cannot be guaranteed and should not be used.
  • By increasing the number of people with safety seats, programs might also increase improper use of safety seats, particularly among new users. Intensive education and practice on proper use of safety seats are important to guard against potential misuse.
  • Implementing organizations need to consider potential liability, the cost of purchasing child safety seats, the logistics around cleaning and storing seats, and staff training.
  • Some child safety seats might be incompatible with certain vehicles.