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The most effective strategy for achieving and maintaining restraint use at acceptable levels is well-publicized, HVE of strong occupant restraint use laws. The effectiveness of HVE has been documented repeatedly in the United States and abroad. The strategy’s three components – laws, enforcement, and publicity – cannot be separated: effectiveness decreases if any one of the components is weak or missing (Nichols & Ledingham, 2008; Tison & Williams, 2010).

These high-visibility, short-duration seat belt law enforcement programs that in the past were called STEPs (selective traffic enforcement programs), “STEP waves,” or “blitzes,” were demonstrated in individual communities in the late 1980s. North Carolina’s Click It or Ticket program took this model statewide beginning in 1993 and raised the use rate above 80% (Williams & Wells, 2004). The Click It or Ticket model expanded nationwide in 2003 (Solomon et al., 2004) and belt use increased in almost all States from 2000 to 2006, in part due to the Click It or Ticket seat belt enforcement programs (Tison & Williams, 2010). Since then, most States have continued to increase or maintain their seat belt use rates. The number of States, DC, and Territories who achieved use rates of 90% or higher increased from 11 in 2006, to 29 in 2019 (NCSA, 2007; NCSA, 2020a).

A recent study examined differences between States with high and low seat belt use and how they approach occupant protection (Thomas et al., 2017). A goal of this study was to identify effective strategies employed by high belt-use States that could be adopted by low belt-use States. There were clear demographic differences in the populations in each group, and low belt-use States had a higher proportion of drivers residing in rural areas. Political and legislative support for general highway safety, and occupant protection was not as strong in low-belt-use States. Several lacked sufficient resources for safety, dedicated occupant protection coordinators, and/or internal research staff, and spent relatively little on media campaigns. Examining these differences in detail led researchers to identify four activities characteristic of the high belt-use States that the low belt-use group could adopt with reasonable expectation 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 in the SHSO; and 4) determine what motivates a State’s population to use seat belts.

Other strategies have been implemented to increase the correct use of child restraints. Child restraint misuse is an issue that has been a concern for many years. In reaction to the high levels of child restraint misuse and incompatibility issues between seat belts and child restraints, a concept of standardized child restraint installation, initially called ISOFIX, was completed as an international standard in 1999 (Klinich et al., 2012).[1] The intent of ISOFIX, later renamed as LATCH (Lower Anchors and Tethers For Children) as implemented in the United States, was to provide a simpler way to install child restraints and reduce misuse using special attachments on the car seat that fasten to anchors built into the vehicle. LATCH consists of two components in the vehicle – the lower anchors and the top tether anchor – with complimentary connectors on the child restraint. However, even with LATCH, misuse remains a problem with forward-facing car seats. The National Child Restraint Use Special Study (NCRUSS) conducted in 2011, found that only 48% of forward-facing child restraints were installed using the top tether, which is an important component of the LATCH system (Greenwell, 2015). It should be noted that at the time of data collection, tether use with car seats installed with the seat belt was not aggressively promoted (MacKay & Walker, 2017).

The NCRUSS examined misuse rates of car seats and booster seats in a nationally representative sample of 4,167 vehicles (Greenwell, 2015). A group of subject matter experts determined what constituted “misuse” of child restraints. Misuse was defined as an installation of the car seat/booster to the vehicle, or restraining the child in such a way that could reduce the protection of the car seat/booster in the event of a crash. Restraint-use errors varied by restraint type. Overall misuse was estimated to be 46%. Estimated misuse by restraint type was 61% for forward-facing car seats, 49% for rear-facing car seats, 44% for rear-facing convertible car seats, 24% for backless booster seats, and 16% for high-back booster seats. The most common errors for rear-facing car seats were more than three inches of lateral movement, car seat angle of less than 30 degrees (if child was less than 1), and harness slack of more than 2 inches. The most common errors for booster seats were lap belt across the abdomen/ribcage, shoulder belt behind arm or back, seat belt not buckled, and child’s head above the vehicle seat back.

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 (CPS) 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). Currently, there are over 41,000 certified CPS technicians and instructors (Safe Kids Worldwide, 2018). One study found that parents and caregivers who were initially taught how to install a child restraint by a CPS technician were more likely to achieve an accurate installation than those who initially learned from other sources, typically the manufacturer’s manual (Mirman et al., 2017).

Child passenger safety inspection stations are places or events where parents and caregivers can receive assistance from certified CPS technicians, and are popular services provided by a variety of local CPS programs. Child passenger safety inspection stations are commonly housed at public health departments, fire departments, LEAs, healthcare organizations, family and social services departments, and other organizations that serve the community, including economically disadvantaged populations. A small study conducted in Florida examined the possibility of providing parents with remote help installing child seats using a phone app that allowed parents to interact directly with a CPS technician located elsewhere (Schwebel et al., 2017). The results reported that the accuracy of installations improved significantly compared to the installation prior to the instruction, and that parents felt more confident about the installation.

[1] ISOFIX or Isofix is International Organization for Standardization standard ISO 13216, specifying the anchoring system for Group 1 child safety seats. It defines standard attachment points to be manufactured into cars, enabling compliant child safety seats to be quickly and safely secured. Isofix is an alternative to securing the seat with seat belts. Seats are secured with a single attachment at the top (top tether) and two attachments at the base of each side of the seat. It has regional names including LATCH ("Lower Anchors and Tethers for Children") in the United States and LUAS ("Lower Universal Anchorage System") or Canfix in Canada. It has also been called the "Universal Child Safety Seat System" or UCSSS.