Traffic Safety Facts

Traffic Tech – Technology Transfer Series

Number 365 February 2009

U.S. Department of Transportation 1200 New Jersey Avenue SE., Washington, DC 20590

National Highway Traffic Safety Administration

Identifying Information That Promotes BeltPositioning Booster Seat Use

Background

Motor	vehicle	crashes	remain	a	leading	cause	of	injury	among	

children	in	the	United	States.	Use	of	appropriate	restraints	

in	 motor	 vehicles	 is	 an	 effective	 strategy	 for	 reducing	 the	

risk	of	injury	and	death	to	child	passengers.	Although	child	

restraint	use	in	the	United	States	for	children	under	age	8	has	

increased	since	1998,	children	ages	4	to	8	continue	to	be	at	

highest	risk	for	sub-optimal	restraint	use.

In	order	to	guide	future	efforts	to	increase	belt-positioning	

booster	seat	(BPB)	use,	this	study	focused	on	identifying	reasons	for	BPB	nonuse	for	children	of	parents	with	a	high	school	

education	or	less.	The	study	concentrated	on	ages	3	(when	

children	are	nearing	the	suggested	transition	point	to	booster	

seats)	to	6	(after	which	they	likely	have	used	seat	belts	for	

several	years).	The	Theory	of	Planned	Behavior	formed	the	

theoretical	foundation	for	the	study.	It	asserts	that	behavior	

is	preceded	by	a	positive	intention	to	perform	the	behavior,	

which	in	turn	is	influenced	by	perceived	benefits,	barriers,	

and	 threats	 to	 performing	 that	 behavior.	According	 to	 this	

theory,	to	promote	BPB	use	it	is	necessary	to	encourage	positive	intentions	toward	BPB	use.	This	can	be	done	by	overcoming	parents’	perceived	barriers	to	BPB	use,	highlighting	

parents’	perceived	benefits	to	BPB	use,	and	reducing	parents’	

perceived	threats	(i.e.,	things	they	worry	about	when	driving	their	children).	This	research	aimed	to:	(1)	identify	factors	

that	influence	parents’	current	child	restraint	use	behaviors	

and	their	intentions	for	future	use,	and	(2)	test	interventions	

that	address	these	factors	as	a	means	to	promote	appropriate	

restraint	use,	particularly	use	of	BPBs.	

Method

This	multi-site	study	used	focus	groups	to	identify	contributing	 factors	 to	 booster	 seat	 nonuse,	 which	 guided	 later	

intervention	testing.	A	first	phase	of	information	collection	

composed	of	12	focus	groups	identified	parents’	perceived	

barriers,	benefits,	and	threats	relating	to	BPBs.	The	second	

phase	 of	 the	 study	 identified	 interventions	 for	 testing	 that	

addressed	 the	 benefits,	 barriers,	 and	 threats	 that	 emerged	

in	 Phase	 1.	A	 literature	 review	 augmented	 by	 a	 review	 of	

interventions	 described	 on	 the	 Internet	 led	 to	 selection	 of	

four	pre-existing	interventions	that	met	search	criteria:	“The	

Buckleteers”	(Injury	Free	Coalition	for	Kids	of	Austin),	a	Cinderella	public	safety	announcement	(NHTSA,	The	Walt	Disney	Company,	and	the	Ad	Council),	“Riding	With	The	Big	

Green	Snake”	(Weiner	and	Seaman	Productions),	and	“Abrocha	Tu	Vida”	(Harborview	Injury	Prevention	and	Research	

Center).	 However,	 not	 all	 relevant	 benefits,	 barriers,	 and	

threats	 were	 addressed	 by	 pre-existing	 interventions.	As	 a	

result,	the	contractor	created	interventions	to	fill	in	the	gaps.	

They	 were	 message	 strategies	 that	 emphasized	 the	 importance	of	booster	seat	laws,	provided	education	about	injuries	

that	are	prevented	by	BPBs,	and	presented	BPBs	as	part	of	

good	parenting.	Phase	3	of	the	study	involved	a	final	wave	of	

focus	groups	that	obtained	reactions	to	the	interventions	and	

explored	whether	the	interventions	motivated	any	changes	

in	intentions	to	use	a	BPB.

Key Findings

In	the	Phase	1	focus	groups,	parents	identified	the	possibility	of	a	crash	as	a	threat	that	concerned	them.	Many	trusted	

their	own	driving	abilities,	but	were	fearful	of	other	drivers	

on	 the	 road.	 The	 parents	 described	 a	 variety	 of	 behaviors	

they	performed	to	avoid	the	possibility	of	a	crash	or	serious	

injury,	including	driving	slowly,	not	driving	in	rainy	weather,	

leaving	early	so	as	not	to	be	in	a	rush,	and	establishing	and	

enforcing	rules	for	their	children	(e.g.,	no	loud	talking;	no	distracting	the	driver;	not	leaving	until	everyone	is	strapped	in	

properly).	Another	perceived	threat	was	being	stopped	and	

ticketed	by	law	enforcement.	This	was	often	cited	as	a	motivating	factor	to	restrain	children	properly	in	the	back	seat,	as	

the	fear	of	fines	was	discussed	frequently.	A	number	of	the	

parents	reported	getting	tickets	or	warnings	for	not	complying	with	existing	law.	The	parents	also	repeatedly	reported	

misinformation	concerning	the	provisions	of	the	child	safety	

seat	laws	in	their	States.	A	third	threat	reported	by	parents	in	

all	groups	was	the	potential	for	children	to	misbehave.	Parents	repeatedly	discussed	the	behaviors	of	children	in	the	car,	

including	shouting,	fighting,	throwing	things,	getting	out	of	

one’s	seat,	hanging	out	the	window,	and	climbing	into	the	

front	seat.	

Regarding	perceived	barriers,	parents	in	the	Phase	1	focus	

groups	 noted	 factors	 that	 they	 and	 their	 children	 disliked	

about	using	child	restraint	systems	(CRSs).	Factors	that	parents	disliked	tended	to	pertain	to	the	use	of	the	seats	(e.g.,	
TRAFFIC TECH	is	a	publication	to	disseminate	information	about	

traffic	 safety	 programs,	 including	 evaluations,	 innovative	 programs,	and	new	publications.	Feel	free	to	copy	it	as	you	wish.	If	

you	would	like	to	receive	a	copy,	contact	Dr.	Angela	Eichelberger,	

Editor,	fax	202-366-7394,	e-mail:	traffic.tech@dot.gov.

1200	New	Jersey	Avenue	SE.,	NTI-130

Washington,	DC	20590

they	were	hard	to	use,	too	large,	and	difficult	to	move	from	

car	to	car).	It	wasn’t	clear	if	they	were	referring	to	child	safety	

seats	or	BPBs.	Many	said	they	were	unsure	whether	BPBs	

were	safe,	often	in	reference	to	low-back	BPBs.	Another	barrier	 was	 a	 perception	 that	 BPBs	 were	 expensive.	 The	 parents	 also	 identified	 barriers	 relating	 to	 how	 they	 felt	 their	

children	would	react	to	BPBs,	including	the	child	complaining,	the	child	thinking	he	or	she	is	being	punished,	the	child	

being	made	fun	of,	the	child	feeling	confined,	and	the	child	

being	uncomfortable.	

Parents	in	Phase	1	saw	safety	as	the	primary	benefit	of	BPBs,	

but	several	of	the	groups	were	unsure	of	any	safety	advantage	over	restraint	by	a	seat	belt	alone.	Features	of	the	BPB	

the	 parents	 liked	 included	 size	 (smaller	 and	 easier	 to	 use	

than	a	car	seat),	and	comfort	(more	comfortable	for	the	child	

than	a	seat	belt	alone).	The	parents	also	posited	benefits	that	

they	thought	their	children	would	find	from	using	a	BPB,	

including	that	the	BPB	was	their	“personal	seat”	or	a	“big	

kid	seat,”	and	that	the	child	could	see	outside	the	window	

when	in	a	BPB.

In	the	Phase	3	focus	groups,	parents	spent	the	first	part	of	the	

sessions	engaged	in	exercises	to	rank	the	top	threats,	benefits,	

and	barriers	as	they	perceived	them.	As	in	Phase	1,	the	risk	

of	injury	and	the	possibility	of	being	stopped	and	ticketed	

were	top	threats	parents	worried	about	when	driving	their	

children.	The	top	benefit	if	they	used	a	booster	seat	was	the	

improved	safety	for	their	children.	The	most	frequently	cited	

barrier	to	using	a	BPB	was	child	resistance.	Another	barrier	

was	lack	of	room	in	the	car.	

Most	of	the	interventions	presented	in	Phase	3	drew	mixed	

or	skeptical	reactions.	The	parents	asserted	that	they	were	the	

ones	who	made	the	decisions	about	restraint	use.	Therefore,	

they	 had	 concerns	 about	 the	 effectiveness	 of	 interventions	

geared	toward	children	(Cinderella;	Buckleteers).	They	also	

considered	some	of	the	interventions	as	being	designed	for	

girls	(Cinderella)	or	younger	children	(Cinderella;	Big	Green	

Snake).	Radio	commercials	about	the	law	sparked	argument	

that	the	child’s	safety	should	be	enough	of	a	motivation	without	 the	 added	 consequence	 of	 a	 ticket.	 White	 and	African	

American	 participants	 were	 not	 as	 receptive	 to	 these	 commercials	as	were	Hispanic	participants	exposed	to	Spanish	

versions.	The	latter	group	felt	there	was	a	lack	of	commercials	promoting	child	safety	and	liked	the	amount	of	detailed	

information	 addressing	 age-appropriate	 restraint	 use.	 Parents	found	the	contractor-developed	parent	tips	video	to	be	

dry.	They	appreciated	that	the	spokesperson	was	a	mother,	

and	many	stated	that	“pulling	over”	to	control	their	children	

would	be	effective	and	intended	on	trying	it.	However,	they	

emphasized	that	although	they	might	have	agreed	with	some	

of	the	messages,	this	intervention	did	not	provide	them	with	

the	motivation	they	needed	to	purchase	and	use	a	BPB.

The	contractor-developed	video	on	crash	injury	received	the	

strongest	reaction	from	the	parents.	This	involved	a	father	

describing	the	consequences	of	a	crash	that	killed	his	wife	

and	 permanently	 injured	 his	 oldest	 daughter,	 who	 was	

using	a	seat	belt	instead	of	an	age-appropriate	BPB.	In	doing	

so,	the	father	articulated	how	a	BPB	works	to	prevent	injury.	

Parents	in	all	groups	said	this	intervention	was	particularly	

eye-opening	because	it	answered	all	of	their	questions	about	

BPBs,	while	also	speaking	to	their	fear	of	a	crash.	Each	group	

spoke	at	length	about	the	crash,	speaking	about	their	fears	

as	well	as	stories	they	had	heard.	Parents	frequently	asked	

for	copies	of	the	video,	hoping	to	show	it	to	their	families	

and	friends.

Discussion

Lack	of	knowledge	about	appropriate	child	restraint	found	

in	 this	 study	 indicates	 that	 previous	 intervention	 tactics	

have	not	adequately	educated	the	public,	particularly	as	to	

why	 4-	 to	 8-year-old	 children	 need	 to	 be	 using	 BPBs.	 This	

study	found	that	effective	interventions	should	include	relevant	 knowledge	 packaged	 with	 messages	 that	 the	 target	

population	deems	strong	and	motivational.	Social	marketing	

research	has	shown	that	a	strong	motivator	is	avoidance	of	

perceived	threats.	In	this	study,	participants	cited	the	potential	of	their	children	being	hurt	in	a	crash	as	the	primary	threat	

they	perceived	in	driving	their	children.	A	clear	educational	

message	toward	appropriate	restraint	use	would	therefore	be	

strengthened	by	being	paired	with	a	message	confronting	the	

possibility	of	injury	resulting	from	a	child	being	improperly	

restrained	in	a	vehicle.

How to Order

For	 a	 copy	 of	 Identifying Information That Promotes Belt-

 Positioning Booster Seat Use (Vol.	1	Summary,	52	pages,	and	

Vol.	 2	Appendices,	 131	 pages)	 prepared	 by	 The	 Center	 for	

Injury	 Research	 and	 Prevention	 at	 The	 Children’s	 Hospital	of	Philadelphia,	write	to	the	Office	of	Behavioral	Safety	

Research,	 NHTSA,	 NTI-130,	 1200	 New	 Jersey	Avenue	 SE.,	

Washington,	DC	20590,	send	a	fax	to	202-366-7394,	or	download	 from	 www.nhtsa.dot.gov.	 Alan	 Block	 was	 the	 project	

manager	for	this	study.