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Effectiveness: 3 Star Cost: Varies
Use: Unknown
Time: Medium

Both the American Academy of Pediatrics and NHTSA recommend children stay rear-facing as long as possible until they outgrow the height or weight limits of the seats, and then use  forward-facing harnesses for as long as possible (Durbin et al., 2018; NHTSA, 2019). However, observational data from the 2017 National Survey of the Use of Booster Seats (NSUBS) show that 5.2% of children under age 1 were moved prematurely to forward-facing child restraints. Similarly, 14.9% of children 1 to 3 were not in a rear- or forward-facing child restraints but were instead in booster seats, the seat belts alone, or were unrestrained (Li & Pickrell, 2018b). Note however, that some 3-year-olds may meet the requirement of a booster seat, so while it is not best practice, it also is not technically “misuse.”

A booster seat is recommended until the lap/shoulder combination belt fits properly on its own, typically when a child is 8 to 12 years old and/or 4 feet 9 inches tall. However, 2017 NSUBS data show that many children are moving into seat belts much earlier than recommended. In 2017 some 20.8% of children 4 to 7 were restrained using seat belts alone and 40.1% were using booster seats. Only 10.7% of children 8 to 12 were using booster seats (Li & Pickrell, 2018b). Due to differences in growth, children may meet the requirements for seat belts or booster seats earlier than their peers. If a child has grown to meet the requirements of a booster seat or a seat belt before reaching the recommended age group, it is not necessarily misuse.

Compared to the 2015 NSUBS, child restraint use in  age groups is either unchanged or slightly higher. In 2017 some 13.7% of children 1 to 3 were rear-facing, slightly more than the 9.4% in 2015. In addition, a smaller number of children 1 to 3 were prematurely moved to booster seats (7.6% in 2017 compared to 13.6% in 2015). There were also more children 4 to 7 riding in car seats or booster seats compared with 2013 (68.5% versus 62.4%) (Li & Pickrell, 2018b).

Use: Communications and outreach campaigns directed at booster-seat-age children are likely common, but no summary is available.

Effectiveness: The effectiveness of communication and outreach strategies has been examined in various ways. Will et al. (2009) used a threat-based message to increase booster seat use among attendees of two large daycare/after-school programs in Eastern Virginia. The intervention included a video made with images to invoke emotions, crash test footage, well-respected experts, and personal stories to convey a message of high-threat consequences without using graphic, “gory” images. The study found significant increases in overall restraint use and booster seat use following exposure to the intervention and concluded that applying messages of high-threat consequences (without gore) to booster seat interventions is a promising approach. Similarly, some studies have also used a different threat-based message (“No Regrets”) with some success (Bryant-Stephens et al., 2013; Winston et al., 2007). Another study found that the strongest predictors of booster seat use among Canadian parents of 4- to 9-year-olds was the parents’ knowledge of the purpose and benefit of booster seat use as well as perceived community norms (Bruce et al., 2011).

The “Strike Out Child Passenger Injury” program used community sports programs to promote booster seat use among 4- to 7-year-olds in 20 rural communities across Alabama, Arkansas, Illinois, and Indiana (Aitken et al., 2013). In the intervention communities, information about proper restraint use was shared in conjunction with T-ball season. In addition to information, parents were given the opportunity to meet with a CPS technician during a T-ball event in order to get a personal assessment and recommendation for proper restraint use. Child restraints and booster seats were provided to families in need and baseball-themed prizes were provided to participants. Control communities received only an informational brochure. Following the short program, proper restraint use increased in intervention communities in 3 of 4 States. This study demonstrated that tailoring a program to fit in an established community event can have a short-term impact on restraint use in a rural community where resources are limited.

Costs: As with enforcement-related communications and outreach, costs vary depending on program quality and delivery.

Time to implement: A good educational campaign will require 4 to 6 months to plan and implement.