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Increasing Child Safety Seat Use

There is strong evidence that when children are safely secured in a motor vehicle using either car seats, booster seats, or a seat belt (depending on age and size of the child) the risk of injury or death is greatly diminished. In 2020, 38% of children under the age of 12 who died in a car crash were not restrained in a safety seat or buckled with a seat belt. Child passenger death rates are higher in rural counties. Certain rural communities continue to be disproportionately impacted. For example, American Indian and Alaska Native children are more likely to be riding as passengers in cars without safety seats.

The American Academy of Pediatrics (AAP) recommends all infants and toddlers should ride in the back seat of a vehicle in a rear-facing car seat as long as possible. Parents should pay close attention to the age, height, and weight limits of each car seat and booster seat used. Once children outgrow a rear-facing car seat, they should then use a forward-facing car seat, and eventually a booster seat that is secured with a harness, for as long as possible. The AAP recommends all children under the age of 13 sit in the back seat of vehicles for enhanced safety.

Evidence-based strategies and promising approaches for increasing child safety seat use include child safety seat laws, child seat distribution and education programs, and healthcare provider training.

Child Safety Seat Laws

The Community Preventive Services Task Force (CPSTF) recommends child safety seat laws as an effective strategy for decreasing rates of injury and death from motor vehicle crashes. Every state in the U.S. and Washington, D.C. has safety seat laws for children that require the use of an approved safety seat for children of specific ages. States have different guidelines for the age at which a child can transition out of a child safety restraint and switch to use of a regular seat belt.

Child Seat Distribution and Education Programs

CPSTF recommends the distribution of child safety seats and educational programs as an evidence-based practice for increasing the use of child safety seats. These programs share information and resources with families about the importance of using child safety seats and provide the seats at no cost. Studies have shown that these types of programs can increase the proper use of safety seats and reduce risks for injury and death. There is also some evidence that educational campaigns at the community-level and incentive programs that offer community members rewards for using car seats can help improve the use of these restraints. Programs can use some of the many injury prevention education materials already developed by Safe Kids Worldwide and adapt for their communities. For example, Safe Kids Wisconsin has many easily accessible materials about child safety seats.

Healthcare Provider Training

Healthcare providers are trusted sources of information for parents and can help educate about the importance of using approved safety seats for children. While most families may know to use child safety seats, especially for infants and newborns, many do not know how to properly install the seats. It can be helpful to incorporate education for parents during patient visits, covering the proper use of these seats, different types of safety seats, and age and size requirements. Some health systems have found ways to embed reminders for providers into electronic health record systems to make sure they educate about the use of child safety seats during well child visits.

Examples of Programs that Increase Child Safety Seat Use

  • Arkansas Children's Injury Prevention Center implements passenger safety stations in various locations throughout the state, where car seat experts can check child safety seats. These checks are designed to ensure the safety of the child seat, correct placement, and fit.
  • Chautauqua Safety Village operates a child safety seat program that educates the community about using child safety seats correctly. The Safety Village has certified technicians who inspect car seats to ensure they are being installed and used correctly and safely.
  • The Tribal Injury Prevention Resource Center provides in-person and virtual safety trainings for tribal nations, including content about child passenger safety and seat belt usage. One course offered has been adapted from the National Highway Traffic Safety Administration (NHTSA) National Standardized Child Passenger Safety Training for people working with American Indian and Alaska Native (AI/AN) communities. They also offer other educational resources related to child passenger safety adapted for AI/AN communities.
  • The Indian Health Service has implemented the Ride Safe program in several tribal communities as part of injury prevention programs. The Phoenix Area Indian Health Service Ride Safe Program is one example. The program includes a guide-based curriculum designed specifically for tribal communities, technical assistance and support with installing child safety seats, and child safety seats that can be distributed among the communities being served.
  • Buckle Up for Life is a national child safety education program implemented by Cincinnati's Children's Hospital Medical Center and Toyota, working with local organizations all over the country. The program connects local organizations with resources, tools, and child car seats free of charge for distribution to people throughout the U.S. One Buckle Up for Life partner organization is the Center for Safe Alaskans (formerly the Alaska Injury Prevention Center), which works to prevent injuries for all Alaskans, including many rural communities in the state. One program element is education about car seat safety use, which includes distribution of car seats and training technicians to check safety seat installation. Thousands of car seat checks have been provided across Alaska and the center offers free training and resources for families.
  • First Ride Safe Ride, a program from the Virginia Department of Health, focuses on educating healthcare professionals about safely securing newborns in car seats for their first ride home from the hospital. The program is free and includes a two-hour training as well as educational materials for healthcare providers and staff at all levels who are responsible for caring for and discharging newborns.
  • Native Children Always Ride Safe (Native CARS) is a community-led project with the goal of improving the use of child safety seats to address disparities in tribal communities. The original project involved six tribes and saw major improvements in car seat use after implementation. From this work, the Native CARS Atlas was also created. The Atlas is a resource other tribal communities can use to adapt the intervention for their specific needs and circumstances. The Atlas includes information about building coalitions, assessing community readiness for change, analyzing data, and implementing program components, including education and car seat distribution.
  • The Jena Band of Choctaw Indian Motor Vehicle Injury Prevention Program (JBCI MVIPP) focuses on preventing injuries and deaths by increasing child safety seat use and educating about state regulations. The program has successfully implemented child passenger safety check events and trained Child Passenger Safety Technicians to guide proper installation for families. They also offer distribution events in the community to ensure that everyone has access to approved safety seats.

Implementation Considerations

State laws differ on requirements for child safety seats. Programs providing education about the use of child safety seats should be tailored to align with local laws and enforcement strategies. American Indian and Alaska Native tribes may have different tribal laws that address motor vehicle safety including child restraint laws. Programs advocating for new tribal public health laws related to motor vehicle safety may need to educate tribal communities about the importance of these laws and partner with tribal law enforcement.

Some programs may offer free distribution of car seats. Programs that distribute or loan out car seats should make sure that the seats are installed properly and checked by a certified technician. Finding ways to partner with Child Passenger Safety Technicians is essential for this step, since training and certification is necessary to check installation. Hosting community events can be an effective practice to reach many families at once.

Every car seat has its own requirements for use based on the child's age, height, and weight. These requirements differ by car seat type and manufacturer. Programs that incorporate free distribution of car seats and booster seats should pair this process with education to ensure car seats are used properly and align with manufacturer requirements. For example, the Strike Out Child Passenger Injury intervention aims to improve use of booster seats for children ages 4-7 in rural communities by providing education with certified technicians and distribution of seats during T-ball games.

Car seats can be expensive, so it is important that programs offering car seat distribution identify funding and partnerships for ongoing support. Funding may come from donations, grants, or local philanthropies and businesses. If car seats are donated, programs should confirm that car seats are not expired according to the manufacturer's expiration date, have not been involved in an accident, and are stored and cleaned appropriately.

Resources to Learn More

Car Seat Information
Provides information on selecting a car seat that fits both child and vehicle, correct use of car seats, installation guidance, choosing booster seats, and use of seat belts by older children.
Organization(s): UC Davis Health Injury and Violence Prevention Program

Car Seat Safety Tips
Offers information about selecting, buying, and installing car seats. Includes car seat safety checklists in several languages.
Organization(s): Safe Kids Worldwide

Car Seats and Booster Seats
Describes different car seat types for infants and children. Details important steps to follow when installing car seats and booster seats for children.
Organization(s): U.S. Department of Transportation, National Highway Traffic Safety Administration

JBCI's First Year Reflections: Barriers, Successes, and Plans for Improvement
Describes successes, challenges, and lessons learned from Tribal Injury Prevention Cooperative Agreement Program (TIPCAP) grantees who participated in a child safety check program. TIPCAP provided educational materials, safety equipment, experiential learning, and child seats and booster seats to support proper usage of car seats for children, and reduce motor vehicle injuries of children in tribal communities.
Author(s): Maxwell, M.
Citation: TIPCAP Newsletter
Organization(s): Indian Health Service, Office of Environmental Health & Engineering
Date: 6/2022

Roadway to Safer Tribal Communities Toolkit
Offers fact sheets, posters, and videos on improving road safety through increased use of seat belts and safety seats for children in American Indian/Alaska Native communities.
Organization(s): Centers for Disease Control and Prevention