Objective: To review the effectiveness of nonlegislative community and clinical programs to increase the rate of child motor vehicle occupant restraint use among children under the age of 5 years.
Method: This was a systematic review of the world's published literature. The Cochrane Collaboration protocol was used to conduct the literature search. The following databases were searched for literature on this topic: MEDLINE, EMBASE, NTIS, PsychINFO, ERIC, Nursing and Allied Health, Transportation Research and Information Service, and EI Compendex. The bibliographies of relevant publications were used to search for additional references.
Selection criteria: Studies were included if they evaluated a clinical or community-based intervention designed to increase the use child restraint devices among motor vehicle passengers under the age of 5 years. Studies of the effects of legislation or law enforcement programs were excluded. All study design types, including randomized controlled trials, controlled trials, and controlled or uncontrolled pre/post evaluations, were included. Studies were excluded if there was either no control group or no baseline data with which to compare outcome data. Studies were also excluded if they did not use observed restraint use as at least one of the outcome measures.
Data collection: Each study was reviewed in depth with special attention to the strength of study design. Outcomes were assessed in terms of the absolute difference in observed restraint use within and/or between groups across study intervals.
Results: A total of 18 studies met inclusion criteria for in-depth review. Pooling of results was not possible because of the large differences between studies with regard to study design, settings, target groups, intervention methods, and units of analysis. There were a total of three randomized controlled trials, four controlled trials without random individual or group assignment, three controlled pre-post evaluations, and eight uncontrolled pre/post studies. Among preschool programs, short-term absolute percentage point gains in seat belt use rates ranged from 12% to 52% but only from 8% to 14% one month or more after the intervention. Among community-based media campaigns, long-term child restraint use increased by an absolute margin of 5% to 14%. Of the eleven peri-partum counseling programs, long-term follow-up revealed gains of 6% to 27% with most between 10% to 15%. Many studies had serious design flaws that could overestimate the magnitude of the effect.
Conclusions: Programs to increase the rate of child restraint use among child occupants of motor vehicles appear to have overall moderate short-term effectiveness. The magnitude of the positive program effects one or more months after the intervention appear to diminish substantially. There is a strong need for high quality randomized controlled trials to determine the long-term effectiveness of child restraint promotion programs.