The need for seat-belts and child restraints

The need for seat-belts and child restraints
The need for seat-belts
and child restraints
1.1 Road traffic death and injury as a worldwide
public health problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.1.1 Worldwide trends in road traffic death and injury . . . . . . . . . . . . . . . . 3
1.1.2 Types of injuries sustained by vehicle occupants. . . . . . . . . . . . . . . . . . 5
1.2 How seat-belts and child restraints prevent or
minimize injury. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1.2.1 What happens in a crash?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1.2.2 How a seat-belt works . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
1.2.3 How a child restraint works . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
1.3 Recommended types of seat-belts and child restraints. . . . . . . 8
1.3.1 Seat-belt design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
1.3.2 Types of child restraints. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
1.4 Effectiveness of seat-belt and child restraint use in
preventing death and reducing injury . . . . . . . . . . . . . . . . . . . . . 12
1.4.1 Effectiveness of seat-belts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
1.4.2 Effectiveness of child restraints. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
1.4.3 Seat-belt wearing rates. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
1.4.4 Child restraint use rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
1.5 Effectiveness of seat-belt and child restraint programmes
at increasing wearing rates by vehicle occupants. . . . . . . . . . . 19
Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
1: The need for seat-belts and child restraints
Seat-belts and child restraints: a road safety manual
his module provides the user with background material on why seat-belts
and child restraints are needed. Such information is important in persuading
political leaders and the public to support seat-belt programmes and policies and in
increasing overall restraint use by drivers and passengers around the world.
The sections in this module are structured as follows:
1.1 Road traffic death and injury as a worldwide public health problem. The
module begins by describing the magnitude of the problem of motor vehicle crashes,
and the resulting injuries that are sustained by occupants. It explains the global
distribution of the problem, noting that if present trends continue, many low- and
middle-income countries are likely to experience an increase in the number of crashes
in the near future as the level of motorization increases.
1.2 How seat-belts and child restraints prevent or minimize injury. This section
describes how seat-belts and child restraints protect vehicle occupants and reduce the
impact of a collision.
1.3 Recommended types of seat-belts and child restraints. The various types of
seat-belts and restraints are described in this section.
1.4 Effectiveness of seat-belt and child restraint use in preventing death and
reducing injury. This section presents evidence from studies that have evaluated the
effectiveness of seat-belts and child restraints in reducing death and injury.
1.5 Effectiveness of seat-belt and child restraint programmes at increasing
wearing rates by vehicle occupants. This section shows how legislation on
compulsory seat-belt use coupled with supportive programmes and enforcement
have been effective in increasing wearing rates.
1.1 Road traffic death and injury as a worldwide
public health problem
1.1.1 Worldwide trends in road traffic death and injury
Road traffic injuries are a major public health problem and a leading cause of death
and injury around the world. Approximately 1.2 million people are killed each year
in road crashes worldwide, with up to 50 million more injured. Over 95% of these
deaths and injuries occur in the low- and middle-income countries of Africa, Asia,
Latin America, the Caribbean and Eastern Europe (1).
Although the global trends in road traffic fatalities over the past 20–30 years have
shown an overall increase, the situation varies considerably between different regions
of the world. In the high-income countries of North America, Western Europe and
Module 1: The need for seat-belts and child restraints
Japan, road deaths fell by approximately 20% between 1980 and 2000. In contrast,
over the same period road deaths increased in low- and middle-income countries
by between 50% and 100%. Data suggest that these trends will continue and that by
2020 road traffic deaths will increase by 83% in low- and middle-income countries,
and decrease by 27% in high-income countries. These figures amount to a predicted
global increase of 67% by 2020 (1).
The extent to which different road users are affected by road traffic injuries also
differs between countries. The distribution of those killed in various modes of
transport in different countries is shown in Figure 1.1. Of those killed on the roads in
high-income countries, the majority are drivers and passengers in cars (2). The data in
Figure 1.1 show that vehicle occupants account for as much as 80% of all road traffic
deaths in the United States of America, but only 10–20% in countries in South-East
Asia, where two-wheeler motorized traffic predominates. However, although in lowand middle-income countries car occupants do not comprise the majority of fatalities
on the road, experience from high-income countries suggests that as car ownership
rises so too will the number of vehicle occupant deaths and injuries. Experience from
rapidly motorizing nations to date concurs with these trends: for example, in 2003
more than 12 000 new cars were registered every day in China, while in Viet Nam
official sources report that 600 new cars are being registered every day (3). The use of
seat-belts and child restraints could prevent many of these deaths and serious injuries
that occur among four-wheeled vehicle occupants.
Figure 1.1 Road users killed in various modes of transport as a proportion of all
road traffic deaths
Delhi, India
Bandung, Indonesia
Colombo, Sri Lanka
Motorized two-wheelers
Motorized four-wheelers
Adapted from reference 1
1: The need for seat-belts and child restraints
Seat-belts and child restraints: a road safety manual
1.1.2 Types of injuries sustained by vehicle occupants
There are three “collisions” that occur in every crash where occupants are
unrestrained. The first collision involves the vehicle and another object, e.g. another
vehicle(s), a stationary object (tree, signpost, ditch) or a human or animal. The
second collision occurs between the unbelted occupant and the vehicle interior, e.g.
the driver hits his chest on the steering wheel or his head on the window. Finally, the
third collision occurs when the internal organs of the body hit against the chest wall
or the skeletal structure. It is the second collision that is most responsible for injuries,
and can be reduced significantly by the use of seat-belts and child restraints.
The most frequent and most serious injuries occurring in frontal impacts to
occupants unrestrained by seat-belts are to the head, followed in importance by the
chest and then the abdomen. Among disabling injuries, those to the leg and neck
occur most frequently (4, 5).
Norway study of head injuries
A study in Norway calculated that head injuries make up some 60% of all
injuries to vehicle occupants. The study concluded that drivers and front seat
passengers who do not use seat-belts suffer almost the same percentage of
head injuries as non-users in rear seats (6).
Failure to use a seat-belt is a major risk factor for road traffic deaths and injuries
among vehicle occupants. Passengers who were not wearing their seat-belts at the
time of a collision account for the majority of occupant road traffic fatalities. In
addition, passengers who do not wear seat-belts and have a frontal crash are most
likely to suffer a head injury.
Although of paramount concern, there is more than just the human suffering
associated with non-use of seat-belts. The financial burden of increased death and
injury severity can have a major impact on the finances of the government and local
communities who are paying for the resources that are required to deal with road
crash victims and their families in the aftermath of a crash.
Module 1: The need for seat-belts and child restraints
1.2 How seat-belts and child restraints prevent or
minimize injury
This section describes what happens during a motor vehicle crash and how seat-belts
and child restraints prevent or reduce the severity of injuries sustained.
1.2.1 What happens in a crash?
When a crash occurs, a car occupant without a seat-belt will continue to move at
the same speed at which the vehicle was travelling before the collision and will be
catapulted forward into the structure of the vehicle – most likely into the steering
wheel if they are driving, or into the back of the front seats if they are rear seat
passengers. Alternatively, they can be ejected from the vehicle completely. Being
ejected from a vehicle drastically increases the probability of sustaining severe serious
personal injury or being killed (7).
Seat-belts as a protection against ejection
The American College of Emergency Physicians advocates the use of seat-belts
as the best protection against ejection in a crash. Ejection from a vehicle is
one of the most injurious events that can happen to a person in a crash, with
75% of all vehicle occupants ejected from a vehicle in a crash dying as a result.
Seat-belts are effective in preventing ejections: overall, 44% of unrestrained
passenger vehicle occupants killed are ejected, partially or totally, from the
vehicle, as compared to only 5% of restrained occupants (8, 9).
The use of seat-belts and child restraints is one of the most important actions that
can be taken to prevent injury in a motor vehicle crash. While seat-belts and child
restraints do not prevent crashes from taking place, they play a major role in reducing
the severity of injury to vehicle occupants involved in a collision. An occupant’s
chance of survival increases dramatically when appropriately restrained.
1: The need for seat-belts and child restraints
Seat-belts and child restraints: a road safety manual
1.2.2 How a seat-belt works
Seat-belts and child restraints are secondary safety devices and are primarily
designed to prevent or minimize injury to a vehicle occupant when a crash has
occurred. Seat-belts and child restraints thus:
• reduce the risk of contact
with the interior of the
vehicle or reduce the severity
of injuries if this occurs;
• distribute the forces of a crash
over the strongest parts of the
human body;
• prevent the occupant from
being ejected from the vehicle
in an impact;
• prevent injury to other
occupants (for example in
a frontal crash, unbelted
rear-seated passengers can be
catapulted forward and hit
other occupants).
A belted occupant will be kept in their seat and thus will reduce speed at the same
rate as the car, so that the mechanical energy to which the body is exposed will be
greatly reduced.
1.2.3 How a child restraint works
(Richard Stanley/FIA Foundation)
Infants and children need a
child restraint system that
accommodates their size
and weight, and can adapt
to cope with the different
stages of their development.
The three-point lap and
diagonal seat-belt used by
adults is not designed for
children’s varying sizes,
weights, and the different
relative proportions of
children’s bodies. For
example, a smaller portion
of a child’s abdomen is
Module 1: The need for seat-belts and child restraints
covered by the pelvis and rib cage, while a child’s ribs are more likely than an adult’s
to bend rather than break, resulting in energy from a collision being transferred to
the heart and lungs (10). Consequently three-point lap and diagonal seat-belts may
lead to abdominal injuries among children, and will not be optimally effective at
preventing ejection and injury among them.
Appropriate child restraint systems are specifically designed to protect infants and
young children from injury during a collision or a sudden stop by restraining their
movement away from the vehicle structure and distributing the forces of a crash over
the strongest parts of the body, with minimum damage to the soft tissues. Child
restraints are also effective in reducing injuries that can occur during non-crash
events, such as a sudden stop, a swerving evasive manoeuvre or a door opening during
vehicle movement (11).
1.3 Recommended types of seat-belts and child restraints
1.3.1 Seat-belt design
This section describes the main elements of seat-belt design. Seat-belt designs
should comply with national or international standards (covered in Module 3 of the
manual). Designs that ensure ease of use will serve to increase wearing rates.
The three-point lap and diagonal seat-belt is the safest and most commonly used
in cars, vans, minibuses, trucks and the driver’s seat of buses and coaches, while the
two-point lap belt is most commonly used in buses and coaches. Seat-belt standards
set out requirements for the width of webbing and buckles, and the ease of operation
and adjustment. In more recent years seat-belts have become integrated into overall
vehicle safety systems that include such devices as pretensioners, load limiters and
Three-point lap and diagonal seat-belt
Rated highly for effectiveness and ease of use, the three-point lap and diagonal
seat-belt is the most commonly used in cars, vans, minibuses and trucks and in the
driver’s seat of buses and coaches. The seat-belt tongue clips into the buckle, which in
the front seats of cars is usually placed on the end of a stiff stalk or directly attached
to the seat. A retractor device is included as part of the belt system as this ensures
unnecessary slack is taken up automatically. This system allows the occupant to
connect the tongue and buckle using one hand, preventing ejection after maintaining
the seating position of the occupant.
1: The need for seat-belts and child restraints
Seat-belts and child restraints: a road safety manual
Two-point lap belt
A two-point lap belt (sometimes called a “single lap belt”) using a retractor device
is inferior to the three-point lap and diagonal seat-belt described above but can be
sufficient to maintain the seating position of the occupant, particularly in coaches or
Crash studies have shown that although the lap belt does fulfil the task of reducing
ejection, it fails to prevent the occupant’s head and upper body moving forward and
hitting the vehicle interior. For the driver, this could result in serious head injuries
from contact with the steering wheel. However, because of the size and mass of
coaches, the severity of injury when involved in a collision with another vehicle is
often minor compared to that other vehicle if it is a car or van.
Single diagonal belt
The single diagonal design does provide better restraint for the upper body of the
wearer than the two-point lap belt, but has been shown to be poorer at preventing
ejection and submarining (slipping under the seat-belt).
Full harness
The full harness (double shoulder, lap and thigh straps with central buckle device)
gives very good protection both from ejection and from interior contact. However,
it is somewhat cumbersome to put on, and cannot be easily operated with one
hand. This is an important factor in achieving a high wearing rate, and thus the
harness only tends to be installed in vehicles used for motor sport, where drivers and
co-drivers are at high risk.
1.3.2 Types of child restraints
The safest place for children aged 12 years and under is in the back seat, properly
restrained in an approved child safety seat. Specially manufactured child restraints
should be used for children. There are a number of different types of restraints.
The main determining factor for choice of a child restraint is the child’s weight
(Table 1.1). Older children who are above the height and weight specifications for
using child restraints require a properly fitting three-point lap and diagonal seat-belt
when riding in a vehicle.
Module 1: The need for seat-belts and child restraints
Table 1.1 Weight categories of child restraints
For children of a mass less than 10 kg
For children of a mass less than 13 kg
For children of a mass from 9 kg to 18 kg
For children of a mass from 15 kg to 25 kg
For children of a mass from 22 kg to 36 kg
Infants under the age of 1 year (Group 0 or 0+)
At birth, the infant head is around a quarter of their total length and about a third
of their body weight. An infant’s skull is very flexible, so a relatively small impact
can result in significant deformation of the skull and brain. The smaller the child,
the lower the force needed for injury. The infant rib cage is also very flexible. Impact
to the chest can result in a large compression of the chest wall onto the heart and
lungs, and some of the abdominal organs. The infant pelvis is unstable and cannot
withstand the forces from an adult restraint system. Infants require their own special
seat designed to cradle them in a crash, and provide protection from many types of
crashes. Some infant seats are convertible; that is, they can revert to a full child safety
seat as the child grows older.
A rear-facing child restraint system (sometimes called an “infant car seat”) provides
the best protection for infants until they are both 1 year of age and at least 13
kilograms (kg) weight. For the best protection, infants should be kept rear facing for
as long as possible. The safest place for infants is in the back seat in an approved rearfacing infant car seat.
Children aged 1–4 years (Group I)
The bone-forming process is not complete until the age of 6 or 7 years,
and throughout childhood a child’s skull remains less strong than that of
an adult. A restraint system needs to limit forward head movement
in a frontal impact and provide protection from intrusion in a
side impact. A child restraint should therefore distribute the
crash forces over as wide an area as possible. Belts and harnesses
need to fit well and be properly positioned as designed by
the manufacturer. The restraint system should also provide
protection from contact with the vehicle interior in both front
and side impacts.
1: The need for seat-belts and child restraints
Seat-belts and child restraints: a road safety manual
The best type of child restraint for young children is the child safety seat. The integral
harness secures the child and spreads the crash forces over a wide area. This seat will
last them until either their weight exceeds 18 kg or they grow too tall for the height
of the adjustable harness.
Children aged 4–6 years (Group II)
Booster seats are best used only when a child has outgrown a safety seat. They are
designed for weights from 15 kg to 25 kg. Children should continue to ride in a
booster seat until the lap and diagonal belts in the car fit properly, typically when
they are approximately 145 centimetres (cm) tall (12). Booster seats raise the seating
position of the child so that the adult seat-belt lies properly across the chest, crossing
diagonally at the child's shoulder rather than the neck, and low across the pelvis. If
the adult belt is too high across the stomach, in a crash serious internal injury could
result, or the child could submarine under the seat-belt. The booster seat has a back
and can provide some protection in a side impact.
Children aged 6–11 years (Group III)
Booster cushions without backs are designed for weights from 22 kg to 36 kg, but
manufacturers are now producing booster cushions with backs that cover the full
15 kg to 36 kg range. Shield booster seats, which have a plastic shield in front of the
child, offer less protection and should not be used. Booster seats for children aged
4–7 years have been shown to reduce injury risk by 59% compared to seat-belts
alone (13).
Recent research suggests that children whose restraints are placed in the centre rear
seating position incur less injuries than those placed on the outer seats, although
this is in contrast to some earlier research that found that the centre seat was not a
safer seating position (14, 15). It should also be noted that although children are best
protected when secured in age-appropriate child restraints, if such restraints are not
available, it is still better to use an adult seat-belt on the child than leave the child
unrestrained on the back seat (16, 17).
Child restraint systems
Currently, most child restraint systems are designed to be installed using the
vehicle’s seat-belt. ISOFIX is a system that uses purpose-designed mounting
points provided in the vehicle to attach the child restraint with a rigid mechanism, rather than using the seat-belt to secure the restraint (18). ISOFIX is
increasingly used in Australia and in Europe, and similar systems have been
adopted in the United States (LATCH) and in Canada (UAS).
Module 1: The need for seat-belts and child restraints
1.4 Effectiveness of seat-belt and child restraint use in
preventing death and reducing injury
1.4.1 Effectiveness of seat-belts
Since the 1960s studies conducted throughout the world have shown conclusively
that seat-belts save lives, when worn and fitted correctly. A review of research on the
effectiveness of seat-belts found that their use reduces the probability of being killed
by 40–50% for drivers and front seat passengers and by about 25% for passengers in
rear seats (Table 1.2) (7). The impact on serious injuries is almost as great, while the
effect on slight injuries is smaller at 20–30%. More detailed analyses indicate that
seat-belts are most effective in frontal impacts and in run-off-the-road crashes, where
the probability of being ejected is high if seat-belts are not worn (19).
Table 1.2 Effect of seat-belts on the probability of personal injury in all types of
collisions (individual effects)
Injury severity
Percentage change in number of injuries
Best estimate
95% confidence interval
Drivers of light vehicles (private cars and vans)
(−55; −45)
Serious injuries
(−50; −40)
Minor injuries
(−30; −20)
All personal injuries
(−33; −23)
Front seat passengers in light vehicles (private cars and vans)
(−55; −25)
Serious injuries
(−60; −30)
Minor injuries
(−25; −15)
All personal injuries
(−29; −17)
Back seat passengers in light vehicles (private cars)
(−35; −15)
Serious injuries
(−40; −10)
Minor injuries
(−35; −5)
All personal injuries
(−36; −6)
Source: Adapted from Table 4.12.1 in reference 7.
The actions of rear seat passengers can affect both injuries that they themselves
might incur and those that may be sustained by the driver or front seat passenger. An
unrestrained rear seat passenger poses a serious threat to any restrained person seated
directly ahead of them (20). Thus the use of seat-belts by rear seat passengers could
not only reduce the likelihood and severity of injury to themselves, but also to drivers
and front seat passengers.
1: The need for seat-belts and child restraints
Seat-belts and child restraints: a road safety manual
Seat-belts and crash fatality rates
Seat-belts are approximately 50% effective in preventing fatalities in crashes
in which motorists would otherwise die. It is estimated that seat-belt use prevented about 15 200 deaths in the United States in 2004. If all passenger
vehicle occupants over 4 years of age in the United States had used seat-belts
in 2004, nearly 21 000 lives could have been saved (that is, an additional
5800 lives) (21).
Cost savings through seat-belt use
Between 1975 and 2000, the United States saved US$ 588 billion in casualty
costs due to seat-belt use. The annual savings have increased significantly as
seat-belt wearing has increased among vehicle occupants. For example, the
annual economic saving due to seat-belt use in 1975 was US$ 1.5 million.
By 2000, that figure had risen to US$ 49.9 million. However, road death and
injury from non-use of seat-belts still costs American society an estimated
US$ 26 billion annually in medical care, lost productivity and other injuryrelated costs (8).
Module 1: The need for seat-belts and child restraints
BOX 1.1: Airbags, seat-belts and child restraints
Airbags are a supplemental restraint system,
designed to add additional protection to seat-belts
in (primarily) frontal crashes over 13 kilometres per
hour (km/h). While airbags have saved many lives,
there have also been deaths attributed to airbags
deploying in crashes that would not have been life
Analysis of deaths involving airbags in the United
States showed that nearly all of the people who
have died from airbagrelated injuries were either
unrestrained or improperly
restrained (22). Most of
the deaths have been
to children and adults of
small stature. Airbags are
a passive restraint system,
deploying automatically in
some types of crashes.
If an occupant is unrestrained, or the vehicle has
an airbag installed but no
seat-belt, it is possible that
the occupant may come
into contact with the airbag before it has fully inflated.
This is also the case for people who need to sit closer
to the steering wheel as a result of their size. Airbags
deploy at approximately 300 km/h. Therefore, vehicle occupants should ensure that they are restrained
regardless of whether or not a vehicle has an airbag
Manufacturers should be aware of the potentially
dangerous implications of installing an airbag
without also fitting a seat-belt, and parents should
never position a child in an infant or child safety
seat in front of an airbag. Some vehicles have been
equipped with an airbag on/off switch requiring
the driver to vigilantly monitor the airbag status to
ensure maximum protection for passengers. More
recently, manufacturers
have designed “secondgeneration” or “smart”
airbags that use sensors
to detect when and at what
speed to deploy, based on
crash configurations and
occupant characteristics.
The safest way to ensure
that children under 12
years of age are not injured
by an airbag is to restrain
them in a rear seat. Drivers
should sit at least 25 cm from the steering wheel,
and be properly restrained to minimize contact with
the airbag if it deploys. The airbag must be reinstalled following each airbag deployment.
BOX 1.2: The trauma care cost of not wearing a seat-belt
Data from the North Carolina Trauma Registry were
analysed to determine the effect of seat-belt usage
on outcome in motor vehicle accidents. Of 6237
persons involved in motor vehicle accidents, data on
seat-belt usage were available for 3396. Of these,
1480 were wearing seat-belts and 1916 were not.
Comparison of hospital charges and outcomes for
the belted and unbelted patients showed that seatbelts could have saved at least 74 lives and US$ 7.2
million. There were 135 deaths among the unbelted
patients (7.0%) and 47 deaths among the belted
patients (3.2%). Head injury was more common and
more severe in unbelted drivers. This is important
because head injury is a major factor in mortality.
Seat-belt usage is associated with a significant
decrease in mortality rate, hospital charges, length
of stay, intensive care unit stay and ventilator requirements (23).
1: The need for seat-belts and child restraints
Seat-belts and child restraints: a road safety manual
1.4.2 Effectiveness of child restraints
Like adult seat-belts, child restraints in cars are intended to keep a child firmly
secured in their seat so that in the event of sudden braking or collision the child is
not thrown against the car interior or ejected from the vehicle. The restraint must
absorb kinetic energy (created by the motion of the child during the crash) without
itself injuring the child and must be easy to use.
A review of the effectiveness of child restraints compared the risk of injury to
children in different seating positions in cars (7). Children who sit in the rear
without child restraints have around 25% lower risk of being injured than children
who sit in the front without restraints. For children using restraints in both seating
positions the risk in the rear is 15% lower than in the front (Table 1.3).
Table 1.3 Effects of child restraints in cars on child’s risk of injury as a passenger
Percentage change in risk of injury
Type of restraint used
Best estimate
95% confidence interval
Restraining children aged 0–4 years in a forwardfacing child restraint
(–70; –30)
Restraining children aged 0–4 years in a rearfacing child restraint
(–90; –70)
Restraining children aged 0–4 years with a seatbelt only
(–35; –29)
Restraining children aged 5–9 years in
appropriate child restraint with seat-belt
(–69; –27)
Restraining children aged 5–9 years using seatbelt only
(–29; –7)
Source: Adapted from Table 4.13.2 in reference 7.
The effect of child restraints varies depending on the type of restraint used. A child
up to 4 years of age has a 50% lower risk of injury in a forward-facing child restraint
and 80% lower in a rear-facing seat. This compares with injury reduction of only 32%
when an adult seat-belt is worn (7).
For children aged 5–9 years, child restraints reduce injury by 52%, whereas for seatbelts alone the reduction is only 19%. For older children aged 10–14 years seat-belts
reduce injury by 46%.
Module 1: The need for seat-belts and child restraints
Promoting booster seat use
A systematic review of interventions to promote booster seat use by children
aged 4­–­8 years showed that combining financial incentives or distribution of
free booster seats with education demonstrated marked beneficial outcomes
for acquisition and use (24).
A review of various United States studies has shown that child safety seats that are
correctly installed and used for children aged 0–4 years can reduce the need for
hospitalization by 69% (25). The risk of death for infants is reduced by 70%, and
that for children aged 1–4 years by 47–54%. Of children aged under 5 years, 485 lives
could have been saved in the United States in 2002 if all the children had been in
child safety seats (26).
It has been estimated in the United Kingdom that new rules on the use of child
restraints rather than adult seat-belts for children up to 135 cm in height or aged 12
years and above will save over 2000 child injuries or deaths every year (27).
1.4.3 Seat-belt wearing rates
Rates of seat-belt use vary greatly between countries, governed to a large extent
by the type of laws that require seat-belts to be fitted in vehicles and cars, and
the laws requiring them to be worn. Rates are also dependent on the degree to
which these laws are enforced (see Figure 1.2). In many low-income countries
there is no requirement for belts to be fitted or used, and rates of use are therefore
correspondingly low. In addition there may be cultural norms that negatively
influence seat-belt wearing rates, particularly among young adult car occupants.
Age and seat-belt use
Compared with older drivers, young drivers and front-seat passengers are less
likely than older drivers and passengers to use seat-belts while in a moving
vehicle (28).
1: The need for seat-belts and child restraints
Seat-belts and child restraints: a road safety manual
Figure 1.2 Use of seat-belts by car drivers/front-seat passengers in urban and non-urban
areas of Finland, 1966–1995
Percentage of drivers/front-seat passengers
wearing seat-belts
wearing of
(>15 years)
Non-urban areas
Urban areas
installation of
seat-belts in
new cars
Introduction of
fines for failure
to wear seat-belts
Information and
Introduction of
199 4
Source: Reference 1.
Table 1.4 shows the wearing rates for selected countries. There is considerable
variation in wearing rates, despite legislation on mandatory use in all countries, and
rates are generally lower in rear seats than in front seats. For many of these countries
there is potential for improvement in wearing rates.
Module 1: The need for seat-belts and child restraints
Table 1.4 Seat-belt wearing rates for selected countries
Front seat
driver %
Front seat
passenger %
Rear seat
Costa Rica
Czech Republic
South Africa
United Kingdom
n/a = not available
Source: UNECE questionnaire and various other published articles (2004).
Fatalities and seat-belt use in European Union
Analysis by the European Transport Safety Council estimates that within the
European Union seat-belts currently reduce driver fatalities by 40%. Wearing
rates in European countries vary widely from around 70% to over 95%. If all
European Union countries were to achieve a 99% wearing rate for drivers, 2400
lives would be saved each year (29).
1: The need for seat-belts and child restraints
Seat-belts and child restraints: a road safety manual
1.4.4 Child restraint use rates
In many high-income countries the use of child restraints is common – with usage
rates up to 90% – but in other countries they are still rarely used. Choosing and
installing the appropriate child restraint system is important. Even in countries where
the use of child restraints is high, such as Sweden, the United Kingdom and the
United States, restraints are frequently inappropriately used or misused. For instance,
a child may be restrained in the wrong system for its age or weight, or the straps or
harnesses may not be adequately secured or entirely left undone, thus placing the
child at an increased risk of both fatal and non-fatal injuries (25).
Appropriate child restraint use may be limited by access and cost, or simply be
impractical because of a large family size. In addition, a number of decisions about
what seat to choose, where to place it and how to install it need to be made by
parents. A lack of awareness about the benefits of appropriate and correctly used
restraints can jeopardize their effectiveness. For instance, a study in Greece found
that the majority of parents (88.4%) positioned their children on the back seat
unrestrained, while 76.1% of those that did put their child into a restraint did not do
this consistently (30).
1.5 Effectiveness of seat-belt and child restraint programmes
at increasing wearing rates by vehicle occupants
The technical effectiveness of seat-belts and child restraints is well researched and
proven. Properly designed and fitted restraints save lives. Once seat-belts have been
installed in a vehicle, the next objective is to ensure that the vehicle occupants use
them. There are a number of ways that this can be achieved. Laws making seat-belt
use compulsory are essential in increasing the wearing of seat-belts in all countries,
especially in low- and middle-income countries, where seat-belt wearing rates are low.
To ensure that a much higher level of seat-belt wearing is achieved, a comprehensive
programme is required (Box 1.3). To be successful, legislation should be preceded by
public information campaigns to raise awareness of the benefits of wearing seat-belts
and to provide information on the requirements of the law. Strong enforcement,
especially in the period immediately after the law is implemented, and continuing
publicity and enforcement campaigns are also required, both before enactment
and during the initial enforcement period. Although legislation is essential, it will
not achieve high wearing rates unless it is part of a comprehensive programme of
legislation, enforcement, publicity, incentives and encouragement.
Module 1: The need for seat-belts and child restraints
BOX 1.3: Strategies to bring about increased seat-belt wearing rates
Seat-belt legislation and enforcement. Introducing
and enforcing a mandatory seat-belt law is needed
if rates of seat-belt wearing are to be increased and
maintained. This usually requires laws ensuring that
all passenger vehicles are fitted with appropriate seatbelts, as well as laws requiring that they are worn. In
the United States, for example, one of the strongest
predictors of seat-belt use among young drivers is a
state’s seat-belt law. Between 2000 and 2004, rates
of seat-belt use were higher and fatality rates lower, in
every age group, in all states that enforced a seat-belt
law compared to those that did not (31).
Ensuring that vehicles are fitted with appropriate
seat-belts. Although rules that require all cars to
be fitted with seat-belts are now in place in most
countries, there is evidence that half or more of all
vehicles in low-income countries may lack properly
functioning seat-belts (32).
Seat-belt public awareness campaigns. Laws mandating seat-belt use should be backed up by public
education campaigns. Such campaigns may focus
on young people, and can be used both to increase
awareness and to help make wearing seat-belts a
social norm.
Community-based projects. Community projects
can employ parents and peers to encourage young
people to wear seat-belts.
It is important to note that most studies that examine the impact of seat-belt laws
have been conducted in high-income countries, where legislation when introduced is
heavily enforced, and is usually preceded by extensive publicity campaigns. Although
it seems very likely that the introduction of seat-belt wearing legislation in low- or
middle-income countries will decrease fatality rates among motor vehicle occupants,
there are several unknown factors. Availability of suitable seat-belts and child
restraints is variable across such countries, and the likely level of enforcement is also
a factor that must be considered. Legislation is most likely to work where seat-belts
are widely fitted as standard, where enforcement is comprehensive and where there
is widespread community education on the benefits of seat-belt use. In low- and
middle-income countries where police resources are constrained and community
attitudes to seat-belt wearing are not supportive of legislation, effective enforcement
requires widespread government support.
Enforcement of seat-belt law in Argentina
In Argentina a seat-belt law was introduced in Buenos Aires in 1992
that raised wearing rates for drivers from 6% to 32% but, due to lack of
enforcement, rates subsequently declined to 13% by 1995. New laws and
campaigns raised the rate to 22% by 2004, but the major gain was made
through an enforcement effort that raised the rate to 77% by February
2005. If that wearing rate could be achieved and maintained across
Argentina, 1000 lives could be saved each year (33).
1: The need for seat-belts and child restraints
Seat-belts and child restraints: a road safety manual
Programmes that have introduced manufacturing or wearing legislation and
delivered a sustained enforcement effort, while using publicity and education to raise
awareness and increase compliance, have proven to be successful in raising wearing
rates. Table 1.5 highlights the achievements of selected countries.
Table 1.5 Increases in front seat-belt wearing rates in selected countries after
the implementation of legislation and campaigns
Wearing rates (%) prior to
legislation and campaigns
Wearing rates (%) after legislation
and campaigns
Costa Rica
Czech Republic
South Africa
United Kingdom
* Differs between states.
Mandatory child restraint laws and their enforcement also lead to an increase in
the use of child restraints and have been shown to be effective at reducing deaths
and injuries among children (25). As with seat-belt programmes, successfully
increasing child restraint use requires appropriate legislation and enforcement, as
well as community-wide information campaigns. As child restraints are not installed
within vehicles like seat-belts but must be purchased and fitted by parents it is
more challenging to achieve high usage rates, especially in low- and middle-income
countries. Module 3 provides more detail on measures to increase child restraint use.
Module 1: The need for seat-belts and child restraints
BOX 1.4: International support for seat-belt wearing
International recommendations provide strong support for countries to implement programmes that
legislate for mandatory seat-belt use. Some countries may use the international policy environment
and international law as a means of providing the
necessary impetus for developing national policies
on seat-belt use. International agreements can also
be used by civil societies to advocate seat-belt law
reform in their own countries.
The World report on road traffic injury prevention recommends that all countries, regardless of their level
of income, follow several good practices, including
“setting and enforcing laws requiring seat-belts and
child restraints for all motor vehicle occupants” (1).
In 2004, the World Health Assembly (WHA) adopted resolution WHA57.10, which recommends Member States,
“especially developing countries, to make mandatory
both provision of seat-belts by automobile manufacturers and wearing of seat-belts by drivers” (34).
The WHA resolution is an international agreement
that can be used by those wishing to influence policy
on seat-belt use as a basis for obtaining political support for this measure. In particular, such a resolution
has direct relevance for ministries of health, who, by
adopting WHA resolutions, undertake to support the
principles enshrined in them.
United Nations General Assembly resolution A/60/5
(2005) “Invites Member States to implement the
recommendations of the World report on road traffic
injury prevention including those related to the five
main risk factors, namely the non-use of safety belts
and child restraints, the non-use of helmets, drinking
and driving, inappropriate and excessive speed, as
well as the lack of appropriate infrastructure” (35).
United Nations General Assembly resolution
A/62/L.43 (2008) repeated the 2005 resolution
call for implementation of the World report on road
traffic injury prevention recommendations.
The seat-belt is an effective safety tool that not only saves lives, but also significantly
reduces the severity of injury that a vehicle occupant may have sustained if they were
not wearing the device. Around half of all deaths of front seat occupants could be
prevented through the correct use of seat-belts.
Motor vehicle users make up a high proportion of overall traffic injuries and deaths
in high-income countries, and in low- and middle-income countries the proportion
is growing as motor vehicle ownership is increasing. It is therefore vital that seatbelt use is increased in these countries to prevent a rapid growth in death and injury
among vehicle occupants.
Children should use restraints that are suitable for their size. Use of the appropriate
type of restraint for a child’s age, height, weight and physical limitations reduces
deaths of children by between 50% and 75%.
Programmes that set and enforce mandatory seat-belt legislation, combined with
public education campaigns, are effective at increasing seat-belt wearing rates and
thus reducing injuries and fatalities. Seat-belt laws that are implemented through
primary enforcement are more effective in increasing wearing rates than laws
implemented through secondary enforcement.
There is strong international support for seat-belt wearing programmes.
1: The need for seat-belts and child restraints
Seat-belts and child restraints: a road safety manual
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