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Motor Vehicle Injury – Child Safety Seats: Distribution and Education Programs


What the Task Force Found

About The Systematic Review

The Task Force 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 Task Force 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.


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Summary of Results

Ten studies qualified for the systematic review.

  • Proper use of safety seats: median increase of 23 percentage points (interquartile interval: 4 to 62 percentage points; 10 studies)
  • Possession of safety seats: median increase of 51% (range: 16% to 93%; 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, including hospitals and clinics, as part of postnatal home visitation, and when provided by an automobile insurance company.

Evidence Gaps

Each Community Preventive Services Task Force (Task Force) review identifies critical evidence gaps—areas where information is lacking. Evidence gaps can exist whether or not a recommendation is made. In cases when the Task Force finds insufficient evidence to determine whether an intervention strategy works, evidence gaps encourage researchers and program evaluators to conduct more effectiveness studies. When the Task Force recommends an intervention, evidence gaps highlight missing information that would help users determine if the intervention could meet their particular needs. For example, evidence may be needed to determine where the intervention will work, with which populations, how much it will cost to implement, whether it will provide adequate return on investment, or how users should structure or deliver the intervention to ensure effectiveness. Finally, evidence may be missing for outcomes different from those on which the Task Force recommendation is based.

Identified 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

  • Included studies evaluated programs that provided free loaner child safety seats, low-cost rentals, or direct giveaways.
  • Programs also 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 simply provided lectures, brochures, or pamphlets on how to use the safety seat, whereas others 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 U.S., Canada, Australia, and Sweden.


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.

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.