Evidence Table 1. Included studies birth to 4 years

Study ReferenceTarget BehaviorStudy DesignPopulation Baseline Data-usageInclusion/Exclusion CriteriaDescription InterventionIntervention FormatFollow-up time framesOutcomesResultsUSPSTF Quality
Population Targeted
Primary care setting - during well child visits
Guyer 19891 Child restraints 0–5 yrs.CCTN: 286,676Inclusion: at least one child in household <19 yrsIG1: Concurrent implementation of five injury prevention projects conducted in healthcare settings and community. Components targeting infant and child safety seat use included injury counseling by pediatricians during WCC visits for children up to age 5 years using Framingham Safety Surveys; promotion of infant safety seat restraints for infants leaving maternity hospitals and in pre-school children.Primary care, hospital-based, and community based programs to reduce accidental childhood injuries.2 yrsBehavioral Outcomes: Self-reported use of child safety restraints from approximately 5% of population.Self-reported use (%):Fair; baseline characteristics not reported but communities matched on important characteristics; outcomes measured at population-level, adjusted for SES
PC component & peripartum hospitalization14 communities in Massachusetts.Age: NRExclusion: NRCG: None of the five injury prevention projects were implemented. (Population had incidental participatory exposure to motor vehicle occupant injury-related interventions: 14% at baseline; 34% at 2 years post-intervention.) Exposure to the intervention assessed through telephone survey grouped respondents into three groups.ParentsHealth Outcomes: Motor vehicle occupant injury rates (age-adjusted); surveillance through hospitals; measured injuries requiring medical treatment in an emergency room, hospitalization, or resulting in death,Pre-Post-
Burns, poisonings, suffocations, falls.Families with children 0–5 yrs.% male: NRIndiv, unclearHarms Measure: NRIG49.165
% minority: NRIntensity: VariedCG49.663.3
SES: NRCounseled on seating location: Unclearp-value:NR
Baseline Data: 49% using child restraintsMVO Injury rates (per 10,000 children)
Adjusted OR 2.78 (1.66, 4.66)a
a=adjusted for socioeconomic status
Kelly 19872 Infant car seatRCTN: 171Inclusion: Attendance at primary care clinic for infant well-child visits.IG: 3-part series of age-appropriate tailored safety information requiring active parent participation given by MD at 6, 9 and 12 month well-child visit,.To reduce incorrect child restraint behavior through tailored education.6 months after first visitBehavioral Outcomes: Child riding without restraints or sitting in front seat, assessed through interview/home visit by blinded staff.% usually riding without restraintFair/Poor; high attrition over 30%, analyze completers only; self-reported outcome and does not specify correct use
PC-pediatricsNew Haven, CTAge: NRExclusion: Did not continue well-child visits due to poor compliance, moving or changing to another physician.CG: Routine safety information as part of well-child visits.ParentsIG: 67
Other behaviors:Community hospital primary care clinic.%male: NRIndividual; PrintHealth Outcomes: NRCG: 70
Home safety: fires and burns; falls; poisoning; drowning; suffocation and choking; injuries due to sharp and heavy objects; electrical hazards.% minority: NR3 contacts for 45 minutes total.P-value: NS
SES: NRCounseled on seating location: UnclearHarms Measure: NR% Usually sitting in front sea
IGIG: 33
N: 85CG: 53
Maternal age: 23.4 yrsP-value: <0.05
% male in household: 18
% minority: 96
SES-receiving welfare: 91
N: 86
Maternal age: 23.6 yrs
% male in household: 20
% minority: 93
SES-receiving welfare: 94
Baseline usage: NR
Primary care setting - during well child visits
Liberato 19893 RCT (randomized clinics)Phoenix, AZN: 900 people observed driving in the clinic parking lot.Inclusion: Parents of children 0–4 receiving outpatient care at clinic.IG: Parking lot-drivers with unrestrained children (0–4 yrs) were given a printed warning; recommended they attain safety seat; advice to avoid a city citation fee by contacting the health educator who would encourage attendance at a formal class. Drivers with restrained children were given sunshade. Waiting rooms-buckle up stickers and cups with information were distributed; waiting room presentation participants were given sun shade; bulletin boards displayed information. Clinic staff (not MDs)-provided verbal reinforcement and incentives when subject arose. Monthly meetings-1 hour by health educator; lottery drawing of car seat.To increase usage of car seats through education; coercion; and incentives.6 months, 12 monthsBehavioral Outcomes: Observed every third car with a passenger 0–4 yrs for car seat usage. Correct usage was not assessed. Assumption that the random sampling was representative of seat usage even though they are not necessarily the direct recipient of the intervention.% safety seat non-usageFair/Poor; unclear if groups similar at baseline; observed outcome but did not specify correct use; unclear if assessor was blinded
Infant/child car seats6 randomly selected county outpatient care clinics.Age: NRExclusion: Excluded from outcomes if did not drive to clinic.CG Pre-intervention: Patients received usual care in maternity and well child clinics regarding importance of safety seats.Parents of children 0–4Health Outcomes: NRmonth 0 6 12
PC-pediatricsMedically indigent% male: NRGroup; indiv; print; other.Harms Measure: NRIG:74.962.3*64.7*
% minority: 66.9% minority: NRCounseled on seating location: No.CG:87.889.170.0**
SES: NR*P<0.05 from baseline
Baseline usage:**NS
IG: 25.1%
CG: 12.2%
Reisinger 19814 Infant car seatCCTN=269Inclusion: Requested three pediatricians within a group practice and came in for at least one f/u visit.IG: Received education regarding infant seat delivered by MD-pediatrician at postpartum hospital stay and well-child visits at 1 and 2 months. Pamphlet and formal prescription at postpartum; tailored message at 1 and 2 months; demonstration by pediatrician of seat use at 1 month.To increase car seat usage through education and tailored counseling and modeling.1, 2, 4, and 15 months.Behavioral Outcomes: Observation of correct use of infant car seat upon arrival for WCC visits% correctly observed using restraintFair; report some but not all important baseline characteristics; blinded observation of outcome, specifying correct use; 5% attrition at 2 months and 23% at 15 months; analyze completers only.
PC-postpartum and PC-well child visitPittsburgh, PAAge: NRExclusion: NRCG: Received educational messages that did not include car seat usage.ParentHealth Outcomes: NR IG CG
% male: 0Indiv, print, modelingHarms Measure: NR1 mo3831
% minority: NR,“almost entirely white”3 contacts over 2 months. Time-NR.2 mo5029
SES:“middle and upper middle class”Counseled seating location: NR4 mo4743
IG15 mo5650
Age: 27 yrs
% male: 0
% minority: NR
Age: 26 yrs
% male: 0
% minority: NR
Baseline usage: NA
Scherz 1976 5 Infant car seatsCCTN: 500Inclusion: Attendance at 4 wk well child visitIG4: Display, pamphlet, 1–5 min with MD-pediatrician encouraging purchase of infant car seat.To increase infant car seat usage through various intensities of education.8 wksBehavioral Outcomes: Correct infant seat use, which included using an approved car seat or car bed attached by seat belt. Self-reported on a survey.% reporting safe car seat usageFair/Poor; Do not report baseline characteristics, report of 100% follow-up at 8 weeks is suspicious; 47% attrition at 9–12 months f/u (results not shown)
PC-pediatricsWell child clinic in an army medical center in Tacoma, WAAge: NRExclusion: NRIG3: Display, pamphlet, 1–2 min from RN encouraging purchase of infant car seat.ParentHealth Outcomes: NRIG4: 22
% male: NRIG2: Display and pamphlet.Indiv, printHarms Measure: NRIG3: 22
% minority: NRIG1: Information display only.Counseled on seating location: NRIG2: 8
SES: NRCG: No stimulusIG1: 12
Baseline Data: NRCG: 9
P <0.001
3&4 vs 1, 2 & CG: P <0.001
Primary care setting - antepartum only
Alavarez 19936 Infant car seatsRCTN: 14Inclusion: NRIG1: At a prenatal visit during the last month of pregnancy with an unspecified type of provider, participants received: discussion of Illinois child passenger legislation; an explanation of the benefits of automobile restraint devices along with behavior modification strategies for use; a list of available infant and toddler restraints; and a demonstration of appropriate use of one type of restraint, and received an infant automobile restraint device on loan for 5 months for a $10 deposit at initial visit.To increase infant car seat use through education, modeling, and access.Discharge, and 6 weeks after dischargeBehavioral Outcomes: Observed correct use of infant safety seatProper use at hospital discharge:Fair - Outcome assessed by blinded observers; 0% attrition but very small sample size
Study #2PC-prenatal visitChicago, ILAge: NRExclusion: NRIG2: Same as above, but the restraint device was made available at the six-week post-partum visit instead of during the last month of pregnancy. ParentHealth Outcomes: NRIG1: 6/7 (86% (c))
Low income Hispanic population% male: 0%IndividualHarms Measure: NRIG2: 1/7 (14% (c))
% minority: 100%1 visitP-value < 0.01
SES: Two single mothers on public assistance, 12 married women whose husbands were laborers.Counseled on seating location: NRProper use at 6 week visit:
Baseline usage: 13 out of 14 infants unrestrained in a random sample of newborns at same clinic.IG1: 4/7 (57% (c))
IG2: 1/7 (14% (c))
P-value NS
Serwint 19967 Infant car seatsRCT-block randomizationN: 156Inclusion: Nulliparous women; ≥ 18 years; fetus of gestational age ≤28 weeks; not yet selected a pediatricianIG: Had a prenatal visit with a pediatrician scheduled between 32 and 36 weeks gestation. Received a welcome letter to the pediatric clinic with a brochure for proper health care utilization. Counseled by a PGY-2 pediatric resident on multiple anticipatory guidance topics if attended visit.To see if prenatal visits to a pediatrician had an effect on health behaviors post-birth2 months post birthBehavioral Outcomes: Child did not always use of child safety seat in last month assessed through questionnaire.Reported use of car seat-last ride:Fair/Poor; High attrition over 30%; analyze completers only; low adherence in IG (57%); self-reported outcome and does not specify correct use
PC-prenatal pediatricsUrban; hospital-based residents' clinicIGExclusion: Admitted prenatal drug use; had a recognized psychiatric illness; or had HIVCG: Not offered a visit, received card with future pediatrician information, welcome letter, and brochure.ParentHealth Outcomes: NRIG (n=54) 77%
Breastfeeding; emergency room visits; circumcision; health maintenance; mother/pediatrician relationshipLow-income;primarily African American familiesN: 81Individual, printHarms Measure: NRCG (n=51) 86%
Age: 20.2 (±2.1)Seating location-NRP-value = 0.33
% male: 0Reported ownership of infant car seat:
% minority (African American): 91IG (n=54) 83%
SES (medical assistance): 98CG (n=51) 94%
N: 75
Age: 20.7 (±2.5)
% male: 0
% minority (African American): 91
SES (medical assistance): 95
Baseline usage: not applicable
Peripartum inpatient setting only
Christophersen 19828 Infant car seatsRCTN=30Inclusion: Delivered a single live born infant; baby's doctor within 10 miles.IG: Discharge staff person brought in a free loaner car seat at time of discharge and then offered to demonstrate proper infant placement in seat before leaving room, carrying infant in seat, and correct restraining with lap belt in family's vehicle. If mother refused, no further effort was made.To increase infant restraint use through demonstration and access to free car seat.Discharge and 4–6 weeks postpartumBehavioral Outcomes: Observed use and correct use of infant car seat.% correct use of restraintFair; observed outcome and low attrition (10% at follow-up) but small sample size and has other methodological flaws
Peripartum hospitalizationSuburban Kansas City HospitalAge: NRExclusion: NRCG: Usual care.ParentHealth Outcomes: NR IG CG
% male: 0Format: individual; demonstration and access.Harms Measure: NRDischarge670 (*)
% minority: NR1 contact, time-2 minutes more than time normally needed to discharge patient.4–6 wks2923 (NS)
SES: NR (see comments)Counseled seating location: Yes.
Baseline usage: NA
Lindqvist 19939 Infant car seatsCCTN: 1157Inclusion: Live birth at the participating hospitals during the test period.IG: An infant car seat was loaned free of charge during the mother's post-partum inpatient hospitalization. Maternity ward staff demonstrated the use of the seat and parents viewed videotape. Seats were returned at 9 months.To increase car seat usage through education and tailored counseling and modeling.9 months and 15 monthsBehavioral Outcomes: Self reported use of car seat by questionnaire.% reporting more or less frequently restrained at 9 months:Fair/Poor - Data are self-reported and correct use is not specified. No effort was made to follow-up on 13% of infants in intervention group whose mothers did not accept the car seat loan.
Peripartum hospitalization(group level)Age: NRExclusion: NRCG: Usual care.ParentHealth Outcomes: Self report of motor vehicle accidents resulting in injuries during 0–9 months.IG: 96.2%
Sweden% male: 0Indiv, print, modelingHarms Measure: NRCG: 49.4%
3 community hospitals in smaller cities.% minority: NR1 contact,Time-NR.P-value: NR
SES: NRCounseled seating location: NR% reporting car seat use at 15 months:
IG IG: 98.7%
N: 764CG: 97.6%
SES-car ownership: 97.9%P-value: NR
CG Motor vehicle accident-related injuries during 0–9 months: No motor vehicle accidents resulted in personal injuries in control or intervention groups.
N: 393
SES-car ownership: 96.4%
Reisinger 197810 Infant car seatsCCTN: 1,103Inclusion: Delivered live baby within the study period.IG1: Received two pamphlets from research staff with training regarding child safety seat use and given in-room access to purchase car seat. Seat delivered to room and correct use demonstrated for women who purchased it.To increase infant restraint use through education and access to care seat, demo modelingDischarge and 2–4 months post-partumBehavioral Outcomes: Observation of correct use of infant carrier (infant care seat restrained with car seat belt.)% use at hospital discharge (85.55 sample)Fair; blinded observation of outcome; measured correct use; report no difference in baseline SES characteristics between groups.
Age: NRExclusion: Babies who were to be adopted; those whose babies died; not English speaking or deaf; no car ownership; not discharged prior to next treatment group initiated.IG2: Same as IG1, but also visit from health educator regarding use of car seatParentHealth Outcomes: NRCG: 6
% male: 0IG3: Same as IG1 and offered free car seat.Format: varied per group: print; individual; access, modelingHarms Measure: NRIG1: 8 (lit+ access)
Peripartum hospitalizationPittsburgh, PA% minority: NR1 contact: education component approximately 10 min for IG2.IG2: 8 (Lit+ access+ health ed)
Postnatal couples prior to dischargeSES: NRCG: Car seats available for purchase in gift shop.Counseled seating location: No.IG3: 11 )lit+ free carrier
Baseline usage: NA% use at follow-up(66.5% sample):
CG: 21
IG1: 22
IG2: 20
IG3: 28
P values: NR
Baseline for behavior: NR
Tietge 198711 Infant car seatsCCTN: 93Inclusion: First time mothers, gave consent, were discharged during experimental period.IG2: Watched 14-min video from Physicians for Automotive Safety (including demonstration of proper use of infant safety seat) and 5 minute face-to-face instruction session which included practice by subjectTo increase infant car seat usage through education and modeling.DischargeBehavioral Outcomes: Observed correct use of infant car seat.% Correct seat usageFair/Poor; 27% attrition (cannot determine if differential); analyzed completers only; excluded 5 women in intervention group who did not watch film.
PC-peripartum hospitalMajor community hospital in San Diego, CAAge: NRExclusion: If could not verify that participant viewed video or were not viewed at discharge.IG1: Viewed video.ParentHealth Outcomes: NRIG2: 74.2
% male: 0CG: Given no safety seat information.Indiv, videoHarms Measure: NRIG1: 68.8
% minority: 16 % (calc)1 contact, 19 minutes totalCG: 63.3
SES: 73.29% had some college or moreCounseled on seating location: NRNS
65.6% ≥$2,000/mo
Baseline usage: NA
Primary care - Referable Education courses
Barone 198812 Car seatRCT - (group level)N: 79 couples or individualsInclusion: Participation in toddler education class; consenting to a home visit and safety assessment; attended health and safety-education presentation; lived in dwelling where they could control the setting of the water heater; not engaging in major water use 2 hrs preceding home visit.IG: Viewed home safety slides; slides addressing water temperature, smoke detectors and child restraints; 6-minute film regarding crash tests of restrained and unrestrained children; education packet; and digital thermometer.Conflict-theory model of decision-making. To increase car seat usage as compared to control.UnclearBehavioral Outcomes: Observed correctly installed car seat.% having correctly installed car seat:Fair/Poor;randomization method unclear; age of children in groups not reported; unclear of outcome assessment was blinded.
PC-R: parent education classesSuburban Kansas City medical center.IGExclusion: NRCG: Viewed home safety slides only.ParentHealth Outcomes: NRIG: 100%
Yes, water temperature, smoke detectorsParents who elected to participate in a continuing-education series.N: 41 couples or individualsGroupHarms Measure: NRCG: 100%
Age, mean yrs: 32-mother, 34-father1 session of 2 hoursNS
% male: NRCounseled on seating location: unclear
% minority: NR
SES-education: 2.98 mean (2=H.S., 3=baccalaureate)
Income: 4.7 mean (4=$31–40,000; 5=$41–50,000)
Baseline usage: NR
N: 38 couples or individuals
Age, mean yrs: 32-mother, 33-father
% male: NR
% minority: NR
SES-education: 2.87 mean (2=H.S., 3=baccalaureate)
Income: 4.54 mean (4=$31–40,000; 5=$41–50,000)
Baseline usage: NR
Goodson 198513 Infant car seatsCCT (group level)N: 163Inclusion: attendance at hospital prenatal class.IG: Half hour lecture given by social worker including a discussion; demonstration of correct use of infant safety seat with a doll; 10-min film by the Insurance Institute for Highway Safety illustrating crash results of unrestrained infant; question and answer session; brochures.To increase use of infant car seat through education and modeling.4–6 months post-partumBehavioral Outcomes: Use of crash-tested car seat on the last ride self-reported during a phone interview.IG: 96.1%Fair/Poor; baseline characteristics are not reported, 17% attrition with analysis of completers only; unclear if outcome assessors were blinded; correct use not specified
PC-R: prenatal classesAge: NRParentsHealth Outcomes: NRCG: 78.3%
% male: 0CG: Usual cursory mention of child passenger safety.Group; film, demonstration, question and answer;Harms Measure: NRP < 0.001
San Francisco% minority: NRExclusion: no car ownership.One 30-min session.
Counseled on seating location: NR
Prenatal couplesSES: NR
Hospital A
N: 67
Age: NR
% male: 0
% minority: 24
SES-Median education: 16 yrs
Hospital B
N: 69
Age: NR
% male: 0
% minority: 77
SES-Median education: 12 yrs
Baseline seatbelt usage of parents:
Hospital A: never wear 6%
Hospital B: never wear 38%

Calc= Calculated Value; CG= Control Group; IG= Intervention Group; Indv. = Individual; N= Number; NR= Not Reported; PC= Primary Care; PC-F= Primary Care Feasible; PC-R= Primary Care Referable; RCT= Randomized Controlled Trial; SES= Socioeconomic Status

From: Appendix F. Evidence Tables

Cover of Primary Care Interventions to Prevent Motor Vehicle Occupant Injuries
Primary Care Interventions to Prevent Motor Vehicle Occupant Injuries [Internet].
Evidence Syntheses, No. 51.
Williams S, Whitlock E, Smith P, et al.

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