Table 1. Summary of Studies Evaluating Counseling to Increase the Use of
Infant and Child Safety Seats during Pregnancy or after Birth to Age 4 Yearsa
| Study, Year (Reference) |
USPSTF Quality
Ratingb |
Study Design |
Sample Size, n |
Timing and Setting |
Groups and Intervention Components |
| Primary care setting
during WCC visits |
| Guyer et al., 198936 |
Fair |
Group CCT |
286,676 (14 communities in Massachusetts) |
Immediate postpartum and WCC visits (1, 9, 12 mo);
peripartum hospitalization, pediatric clinics, and community settings |
IG: Concurrent implementation of 5 injury prevention
projects conducted in health care settings and the community; components targeting
infant and child safety seat use included tailored injury counseling by pediatricians
during WCC visits for children up to age 5 years using Framingham Safety Surveys and
promotion of infant safety seat restraints for infants leaving maternity hospitals and
in preschool-age children
CG: None of the 5 injury prevention projects were implemented; population had incidental
participatory exposure to MVOI-related interventions: 14% at baseline, 34% at 2 y
after intervention
Exposure to the intervention was assessed through telephone survey |
| Kelly et al., 198727 |
Fair to poor |
RCT |
171 |
6-, 9-, 12-mo WCC visits; primary care clinic |
IG: Tailored safety information targeting multiple
injury prevention behaviors given by physician at 6-, 9-, and 12-mo WCC visits
CG: Routine safety information as part of WCC visits |
| Liberato et al., 198928 |
Fair to poor |
Group RCT |
6 randomly assigned clinics; samples of 900 children at
3 time points |
WCC visits for children age 0–4 y; county primary care
clinics |
IG: Parking lot warnings, brief advice, rewards for
use; distribution of stickers and cups, information and presentation with
distribution of sunshades in waiting rooms; bulletin boards displayed information;
clinic staff (not physicians) provided verbal reinforcement and incentives when
subject arose; monthly 1-h meetings with health educator; lottery drawing of car seat
CG: Patients received usual care in maternity and WCC clinics on the importance of
safety seats |
| Reisinger et al., 198137 |
Fair |
CCT |
269 |
Immediate postpartum and WCC visits (1 and 2 mo);
peripartum hospitalization and pediatric clinics |
IG: Counseling by pediatrician at postpartum hospital
stay and WCC visits at 1 and 2 mo. Pamphlet, formal prescription at postpartum visit;
tailored message at 1 and 2 mo; demonstration by pediatrician of seat use at 1 mo
CG: Received educational messages that did not include car seat use |
| Scherz, 197638 |
Fair to poor |
CCT |
500 |
4-wk WCC visit; WCC in U.S. Army medical center |
IG4:
Display, pamphlet, 1–5 min with physician-pediatrician encouraging purchase
of infant car seat
IG3: Display, pamphlet, 1–2 min with registered nurse encouraging purchase
of infant car seat
CG: No stimulus |
| Primary care
setting during antepartum period only |
| Alvarez and Jason, 199329;
study 2 |
Fair |
RCT |
14 |
Antepartum period; outpatient prenatal clinic |
IG1: Educational counseling about infant safety seats
by unspecified prenatal provider in last month of pregnancy; list of available infant
and toddler restraints; infant safety seat loan; demonstration of correct use
IG2: Same as IG1, but infant safety seat loan was available at the 6-wk postpartum
visit |
| Serwint et al., 199630 |
Fair to poor |
RCT |
156 |
Antepartum period; pediatric clinic |
IG: Prenatal visit scheduled with a pediatrician
between 32 and 36 wk of gestation; counseling by a pediatrician on multiple
anticipatory guidance topics
CG: Welcome letter and general brochure about pediatric practice; no visit scheduled |
| Peripartum
inpatient setting only |
| Christophersen and Sullivan, 198231 |
Fair |
RCT |
30 |
Immediate postpartum period; peripartum hospitalization |
IG: Free loaner infant safety seat just before
discharge, with demonstration of correct use
CG: Usual care |
| Lindqvist, 199339 |
Fair to poor |
Group CCT |
3 community hospitals in Sweden; 1157 persons |
Immediate postpartum period; peripartum hospitalization |
IG: Free loaner infant safety seat, demonstration
of correct use, videotape
CG: Usual care |
| Reisinger and Williams, 197840 |
Fair |
CCT |
1103 |
Immediate postpartum period; peripartum hospitalization |
IG3: Pamphlets, free car seat, demonstration of
correct use (n = 265)
CG: Usual care (n = 272) |
| Tietge et al., 198741 |
Fair to poor |
CCT |
93 |
Immediate postpartum period; peripartum hospitalization |
IG2: 14-min video from Physicians for Automotive
Safety (including demonstration of proper use of infant safety seat) and 5-min,
face-to-face instruction session, which included practice by participant
IG1: Viewed video
CG: Given no safety seat information Referable to primary care; education courses |
| Barone, 198832 |
Fair to poor |
RCT |
79 couples or individuals |
Unspecified; hospital-affiliated course for
parents of toddlers |
IG: Viewed home safety slides; slides addressing
water temperature, smoke detectors, and child restraints; 6-min film on crash
tests of restrained and unrestrained children; received education packet and
digital thermometer
CG: Viewed home safety slides only |
| Goodson et al., 198542 |
Fair to poor |
Group-level CCT |
163 |
Antepartum period; hospital-based prenatal class |
IG: 30-min lecture by social worker with discussion
and demonstration of correct use of infant safety seat; 10-min film by the
Insurance Institute for Highway Safety; question-and-answer session; brochures
CG: Usual cursory mention of child passenger safety |
(Table 1, continued)
| Study, Year (Reference) |
Outcome Measured for Assessment |
Observation Time Point |
Results (IG vs. CG) |
Absolute Difference (IG vs.
CG) (95% CI), percentage pointsc |
Comments |
| Primary
care setting during WCC visits |
| Guyer et al., 198936 |
Self-reported use of child safety restraints
from random-digit dialing survey of approximately 5% of population
Motor vehicle-related injury or death assessed through injury surveillance
at hospitals |
Before intervention
2 y after intervention
Before intervention
During 2-y intervention |
Restraint use: 49.1% vs. 49.6%
Restraint use: 65.0% vs. 63.3% (P = NR)
Age-adjusted MVOI rates per 10 000 children: 46.54 vs. 44.53
Age-adjusted MVOI rates per 10 000 children: 21.54 vs. 60.77
OR, 2.78 (95% CI, 1.66 to 4.66)d |
1.7
-39.23 MVOIs per 10 000 children |
Unable to calculate attrition or CIs |
| Kelly et al., 198727 |
Self-reported use of restraints (calculated
from reported riding without restraints) |
6 mo after first visit |
33% vs. 30% (P = NS) |
3 (-15 to 20) |
Improvement in percentage usually sitting
in front seat (33% vs. 53%; P < 0.05); 36% attrition
at 6 mo |
| Liberato et al., 198928 |
Observed use (calculated from nonuse) |
Baseline
6 mo
12 mo
(after program began; follow-up among sampled individuals varied) |
IG, 25.1%; CG, 12.2%
IG, 37.7%e; CG, 10.9%
IG, 35.3%e; CG, 30.0%f |
NA |
Included incentives and rewards; medically
indigent population, 66.9% minority; attrition NA because outcome was
assessed among 3 samples, not entire study population |
| Reisinger et al., 198137 |
Observed correct use |
1 mo
2 mo
4 mo
15 mo |
38% vs. 31%
50% vs. 29%
47% vs. 43%
56% vs. 50%
P = NR |
7 (-4 to 19)
21 (10 to 33)
4 (-8 to 17)
6 (-8 to 19) |
Mostly white, middle and upper middle class
population; 0% attrition at 1 mo, 5% attrition at 2 mo, 11% attrition
at 4 mo, and 23% attrition at 15 mo |
| Scherz, 197638 |
Self-reported correct use |
8 wk after intervention |
IG4: 22%
IG3: 22%
CG: 9%
P <0.001 overall
P <0.001 for IG3 and IG4 vs. IG1, IG2, and CG |
13 (3 to 23) |
0% attrition at 8 wk (suspicious for reporting
error); 43% attrition at 9-12 mo (results not included) |
| Primary
care setting during antepartum period only |
| Alvarez and Jason, 199329;
study 2 |
Observed correct use |
Discharge
6 wk after discharge |
86% vs. 14% (P < 0.01)
57% vs. 14% (P = NS) |
72 (35 to 100)
43 (-2 to 88) |
Included infant safety seat distribution
through loan program; low-income, Hispanic population; 0% attrition at
discharge, 0% attrition at 6 wk after discharge |
| Serwint et al., 199630 |
Self-reported use during last ride |
2 mo after birth |
77% vs. 86% (P = NS) |
-9 (-23 to 6) |
Intervention addressed multiple other anticipatory
guidance topics; low-income, primarily African-American population; 32%-33%
attrition at 2 mo |
| Peripartum
inpatient setting only |
| Christophersen and Sullivan,
198231 |
Observed correct use |
Discharge
4-6 wk after discharge |
67% vs. 0% (P < 0.05)
29% vs. 23% (P = NS) |
67 (43 to 91)
6 (-27 to 38) |
0% attrition at discharge; 10% attrition
at 4-6 wk after discharge |
| Lindqvist, 199339 |
Self-reported use |
9 mo
15 mo |
96.2% vs. 49.4% (P = NR)
98.7% vs. 97.6% (P = NR) |
46.8 (42 to 52)
1.1 (-1 to -3) |
Excluded 13% of infants in intervention group
who did not accept car seat loan; 14% attrition at 9 mo, 15% attrition
at 15 mo |
| Reisinger and Williams, 1978
40 |
Observed correct use |
Discharge
2-4 mo after discharge |
11% vs. 6% (P = NR)
28% vs. 21% (P = NR) |
5 (-0.4 to 10)
7 (-1 to 17) |
15% attrition at discharge, 34% attrition
at 2-4 mo after discharge |
| Tietge et al., 198741 |
Observed correct use |
Discharge |
IG2 vs. CG: 74.2% vs. 63.3%
IG1 vs. CG: 68.8% vs. 63.3%
(1 x 3 ANOVA NS) |
IG2 - CG: 10.9
IG1 - CG: 5.5 |
16% minority; 73% had at least some college
education; 27% attrition at discharge; unable to calculate 95% CIs for
absolute difference because raw data NR |
| Barone, 198832 |
Observed correct use |
Unclear |
100% vs. 100% |
0 |
100% use in population may be due to high
SES, educated study population; 0% attrition, but timing of outcome assessment
is unclear; unable to calculate CIs for 0% difference |
| Goodson et al., 198542 |
Self-reported use during last ride |
4-6 mo after birth |
96.1% vs. 78.3% (P < 0.001) |
17.8 (6 to 29) |
Results were not different at 1 of the 2
hospitals where both IG and CG reported high use (97.5%-100%);
17% attrition at 4-6 mo after birth |
Notes:
a. ANOVA = analysis of variance; CCT = controlled clinical trial; CG = control group;
CI = confidence interval; IG = intervention group; MVOI = motor vehicle occupant injury;
NA = not applicable; NR = not reported; NS = not significant; OR = odds ratio;
RCT = randomized, controlled trial; SES = socioeconomic status; USPSTF = U.S. Preventive
Services Task Force; WCC = well-child care.
b. The USPSTF quality criteria are described
in Appendix Table 5.
c. Absolute differences are reported in
percentage points, unless otherwise noted.
d. Adjusted for SES.
e. P <0.005 from baseline.
f. P not significant from baseline.
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