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Significant effort has resulted in the high observed seat belt use rates seen today. In 1983, before the first seat belt law went into effect, seat belt use was only 14% (IIHS, 2022). Through a combination of seat belt laws, enforcement, and media publicity, the social norms around seat belt use have changed. Today, States commonly record seat belt use rates of 90% or higher. However, many States have not achieved such high belt use rates, and substantial disparities in belt use rates exist even within States with high overall belt use rates.

A recent study examined differences between States with high and low seat belt use on how they approach occupant protection to identify effective strategies employed by high-belt-use States that could be adopted by low-belt-use States (Thomas et al., 2017). There were clear demographic differences between the populations of high- and low-belt-use States (for example, low-belt-use States had higher proportions of drivers residing in rural areas). Political and legislative support for occupant protection and general highway safety were not as strong in low-belt-use States. Further, several of these low-belt-use States lacked sufficient resources for safety, did not have dedicated occupant protection coordinators, spent relatively little on media campaigns, and lacked internal research staff. Examining these differences led researchers to identify four programmatic activities characteristic of high-belt-use States that low-belt-use States could adopt with a reasonable expectation that they would increase seat belt use. These included: (1) build political, law enforcement, and community support to promote seat belt use; (2) increase enforcement of seat belt laws throughout the year; (3) develop in-house research and data analysis capabilities within the SHSO; and (4) determine what motivates a State’s population to use seat belts.

Research has shown that caregivers sometimes have difficulty using car seats correctly. Benedick et al. (2020) examined the factors that influence choosing and using a child restraint correctly. They found that while participants were generally able to select an appropriate car seat for a hypothetical child, over two-thirds (68%) of installation attempts and nearly three quarters (71%) of attempts at restraining a doll (either by harness or seat belt) had errors. Interestingly, there was not a significant difference in the percentage of errors among novice and experienced car seat users. Despite the high percentage of actual errors, participants generally expressed confidence in their attempts, indicating an overconfidence in their abilities.

Hall et al. (2018) conducted focus groups with Australian caregivers to better understand barriers and motivators to correct child restraint use. While caregivers were aware that correct use was important, they were not confident in their abilities to correctly use restraints. Commonly cited barriers to correct use included difficulty understanding child restraint use information and a lack of understanding of how to use the restraint correctly.

These findings are not surprising given the high rates of child restraint misuse seen in the United States. The National Child Restraint Use Special Study (NCRUSS), a nationally representative sample from 2011, found 46% of car seats and booster seats each had at least one major error to installation or use that could reduce the effectiveness of the seat in a crash (Greenwell, 2015). A convenience sample of caregivers who brought their car seats to inspection stations in Los Angeles found nearly all seats had some misuse, though the definition of misuse was broader than used in NCRUSS (Bachman et al., 2016). Other studies show caregivers have difficulty with certain aspects of installation. For example, a study testing different labeling instructions to help caregivers correctly use a tether in pickup trucks found that while the tethers were used in 93% of installations, they were only correctly used in 9% (Klinich et al., 2018).

In order to combat this misuse, programs have been implemented to provide parents and other caregivers with “hands-on” assistance with the installation and use of child restraints. The NHTSA Standardized Child Passenger Safety Training Course, complemented by the national certification process (funded by NHTSA and administered by Safe Kids Worldwide) developed and implemented a system to train safety professionals and other interested parties in the fundamentals of correctly choosing and installing the proper car seat for child passengers and correct placement of the child in the car seat. People who successfully completed the course are certified to educate the public in using child restraints properly and provide caregivers with this “hands-on” assistance (Womack et al., 2005). At the end of 2019 there were over 43,000 certified CPS technicians and instructors (Safe Kids Worldwide, 2019).

Additionally, it is important to acknowledge how restraint use of one occupant relates to another. Several studies have identified a link between adult and child occupant restraint status (Benedetti et al., 2017; Lee et al., 2019; Raymond et al., 2018; Starnes, 2003; Vachal, 2019). A study of child passengers in North Dakota found that when drivers were wearing their seat belts, children were 35 times more likely to be restrained than when the driver was not wearing a seat belt (Vachal, 2019). In other words, children are more likely to be restrained when the adults in the vehicle are also restrained. Additionally, a nighttime observational study in Tennessee found a link between front-seat passenger belt use and driver belt use, where 82% of front-seat passengers were restrained when drivers were also restrained, compared to just 42% when drivers were not restrained (Boakye et al., 2019).