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.
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)
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.
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)?
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?