Motor Vehicle Injury Child Safety Seats: Incentive and Education Programs

Summary of CPSTF Finding

The Community Preventive Services Task Force (CPSTF) recommends interventions that use incentive and education programs based on sufficient evidence of their effectiveness in increasing safety seat use.


Incentive and education programs reward parents for correctly using child safety seats or directly reward children for correctly using safety seats. These programs also include education that varies with regard to content, duration and intensity, and methods used.

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 4 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

Four studies qualified for the systematic review.
  • Baseline rates of safety seat use: 26 percentage points (interquartile interval [IQI]: 11 to 48 percentage points; 4 studies)
  • Observed child safety seat use (assessed between 1 and 4.5 months after programs were conducted): median increase of 9.9 percentage points (IQI: 4.8 to 36 percentage points; 4 studies)

Summary of Economic Evidence

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


Results should be applicable to a variety of populations and settings using a variety of rewards.

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?)

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).


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?

Study Characteristics

  • To receive rewards, parents had to show correct use of safety seats.
  • Rewards used in the included studies ranged from inexpensive trinkets, stickers, or coupons for fast food meals or movies to relatively expensive prizes donated by community merchants.
  • In all programs, larger rewards were provided to randomly selected eligible participants. Some programs also gave smaller rewards to all eligible participants.
  • All of the evaluated programs included educational components of varying intensity. Some programs simply provided information about the reward program itself, whereas others provided information about existing laws on safety seat use and the importance of using safety seats.
    • Programs also varied in how they provided information: some used only brochures or other printed materials; others used more interactive educational and behavioral techniques, such as supervised practice of correct safety seat use, signed pledge cards, and educational videos.
  • Included studies evaluated programs implemented in day care centers and as community-wide efforts in a variety of target populations (including parents of children of varying ages, all socioeconomic groups, urban and rural populations, white and African-American populations), all showing similar increases in safety seat use.


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Zaza S, Carande-Kulis VG, Sleet DA, et al. Methods for conducting systematic reviews of the evidence of effectiveness and economic efficiency of interventions to reduce injuries to motor vehicle occupants. American Journal of Preventive Medicine. 2001;21(4S):23-30.

Centers for Disease Control and Prevention. Motor-vehicle occupant injury: strategies for increasing use of child safety seats, increasing use of safety belts, and reducing alcohol-impaired driving. MMWR. 2001;50(RR-7):1-13. Available at:

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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

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

Foss RD. Evaluation of a community-wide incentive program to promote safety restraint use. Am J Public Health 1989;79:304 6.

Roberts MC, Layfield DA. Promoting child passenger safety: a comparison of two positive methods. J Pediatr Psychol 1987;12:257 71.

Roberts MC, Turner DS. Rewarding parents for their children’s use of safety seats. J Pediatr Psychol 1986;11:25 36.

Stuy M, Green M, Doll J. Child care centers: a community resource for injury prevention. J Dev Behav Pediatr 1993;14:224 9.

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

Barriers to implementation of incentive and education programs were not identified in the literature but implementing organizations should consider the following.
  • Cost of purchasing incentive rewards
  • Resources to maintain appropriate schedules of reinforcement
  • Training of personnel to provide the education component
  • Needed support of schools, daycare centers, and other sites to sponsor incentive and education programs