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Cover of Primary Care Interventions to Prevent Motor Vehicle Occupant Injuries

Primary Care Interventions to Prevent Motor Vehicle Occupant Injuries

Evidence Syntheses, No. 51

Investigators: , MD, MPH, , MD, MPH, , RN, BSN, , MD, MPH, and , MS.

Author Information and Affiliations
Rockville (MD): Agency for Healthcare Research and Quality (US); .
Report No.: 07-05103-EF-1

Structured Abstract


Motor vehicle-related injuries are the leading cause of death among children, adolescents, and young adults ages 3–33 years, and are a major cause for other age groups. Despite the proven efficacy of occupant restraint devices and reducing drinking and driving behaviors in preventing motor vehicle occupant injuries (MVOI), a significant proportion of those killed are either unrestrained or using alcohol. Restraint use for children younger than 9 years is further complicated by the need to properly use age- and weight-appropriate child safety seats or belt-positioning booster seats and children under 13 years should ride in the rear of the vehicle.


This evidence synthesis examines the evidence for the benefits and harms of counseling primary care patients to use age- and weight-appropriate motor vehicle occupant restraints and to reduce alcohol-related driving or riding behavior.

Data sources:

We developed an analytic framework and four key questions to represent the logical evidence connecting primary care behavioral counseling (BC) interventions to increase correct age- and weight- appropriate restraint use with reduced motor vehicle occupant injuries (MVOI). The framework also represented the evidence connecting primary care BC interventions to reduce alcohol-related driving or riding with MVOI. We searched Medline, Cochrane Central Registry of Controlled Trials, Cochrane Database of systematic Reviews, PsycINFO, CINAHL, and Traffic Research Information Service from 1992 to July 2005. Separate literature search strategies were developed for interventions targeting correct use of motor vehicle occupant restraints, alcohol-related driving or riding behaviors, and counseling-related harms. We also reviewed trials included in seven recent systematic evidence reviews, contacted experts, and checked bibliographies from selected trials. We examined 1289 abstracts and 155 full-text articles.

Study Selection:

We included fair-to-good quality research (according to USPSTF criteria), in all age groups (including expecting parents during pregnancy), that evaluated interventions for general primary care populations and were conducted in the following settings: 1) primary care, 2) feasible for conducting in primary care setting, 3) peripartum inpatient hospitalization, 4) and settings feasible for referral from primary care. For all key questions, we considered evidence published in English and conducted in the USA or other similarly developed countries, from the following study designs: randomized clinical trials (RCTs), controlled clinical trials (CCTs), and comparative observational research designs.

Data Extraction:

One reviewer abstracted relevant information from each included article into standardized evidence tables, and a second reviewer checked key elements. Two reviewers graded the quality of each article using USPSTF criteria. Excluded articles were listed in tables, along with the primary reason(s) for exclusion.

Data Synthesis:

One fair-quality, group-level CCT reported a reduction in MVOI among children up to age five in an intervention community compared to a control community (39.2 fewer injuries per 10,000 children per year during the intervention period). This study evaluated counseling to increase restraint use in inpatient and primary care settings as part of a multi-faceted, community-wide approach to reducing MVOI and other injuries. Due to the nature of the trial, the impact of the clinical component cannot be separately determined, although MVOI strategies were not strongly addressed elsewhere in the community interventions. In the same study, rates of motor-vehicle restraint use were not statistically different between groups, although the timing of the measurement could explain this discrepancy.

Six RCTs and seven CCTs (all fair or fair/poor quality) evaluated counseling parents of infants or children up to five years of age or pregnant women. Evidence from studies evaluating counseling in the primary care setting provide fair evidence of an increase in restraint use at two months and evidence of diminished effects at later time points, often due to increased use in the control group at later time points. Two CCTs (fair and fair/poor quality) evaluating education delivered to parents in the peri-partum hospitalization also included an infant safety seat distribution program and found a large increase in restraint use (absolute difference 47% to 67% at discharge or nine months follow-up), but evidence from a fair quality CCT found no increase. Evidence from primary care referable settings and from an inpatient education-only study was mixed.

One fair/poor-quality RCT that evaluated booster seat education by a certified car seat technician in an emergency department setting provided fair/poor overall evidence of a large increase in use one month after the intervention among families that received education and a free booster seat.

One fair-quality CCT that evaluated pediatrician-delivered counseling for children or adolescents to wear seat belts provide fair evidence of increased use immediately after the intervention. A fair-quality, large RCT addressing fifth and sixth graders (about three-quarters of whom were using seat-belts at baseline), however, demonstrated no increased use at 12–36 months follow-up during an office-based injury prevention intervention. Only one trial evaluated counseling adults to wear seat belts and this study found no difference between intervention and control groups six months after the intervention.

We identified no trials that evaluated counseling primary care patients to reduce drinking and driving or to avoid riding with impaired drivers, and no trials that evaluated the harms of MVOI-related BC interventions.


Primary care behavioral counseling interventions to increase correct age- and weight-appropriate restraint use may increase short-term use, or correct use, of restraints but effects may diminish by longer term follow-up. Effective interventions targeting infants or children included education and demonstrations of correct use, with or without child safety seat distribution programs, and were tested during a time of growing cultural support and increasing regulatory requirements for child safety restraint use. Data from primary care studies were limited for interventions to increase use of belt-positioning booster seats for children ages four-eight years, an area where interventions are needed due to lower use and gaps in current child safety seat legislation. No primary care interventions targeting young drivers aged 16–24 years, a known high-risk group, were available. Data to address BC interventions for adults was quite limited, although current data suggests usage rates are quite high and supported by a strong regulatory environment. Across age groups, there was a lack of recent or good-quality trials for any MVOI-related safety behaviors. Many of the available studies were conducted when restraint use was less common and the studies that were conducted in populations with higher baseline use did not show improvements in restraint use, suggesting a possible ceiling effect. Misuse of child safety restraints remains common and diminishes their effectiveness. Extrapolating from existing evidence, interventions to counsel parents on appropriate correct use of child safety seats (including booster seats) may be beneficial, with potential harms unlikely and not supported by data.


This report is based on research conducted by the Oregon Evidence-based Practice Center (EPC)1 under contract to the Agency for Healthcare Research and Quality (AHRQ)2, Rockville, MD (Contract No. 290-02-0024), Task Order Number 2.

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.

The information in this report is intended to help clinicians, employers, policymakers, and others make informed decisions about the provision of health care services. This report is intended as a reference and not as a substitute for clinical judgment.

This report may be used, in whole or in part, as the basis for the development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.


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Bookshelf ID: NBK34023PMID: 20722149


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