• John W Hafner, Stephanie J Kok, Huaping Wang, Dale L Wren, Mary E Aitken, Beverly K Miller, Byron L Anderson, and Kathy W Monroe.
• From the *Department of Emergency Medicine, University of Illinois College of Medicine at Peoria OSF Saint Francis Medical Center; †Department of Emergency Medicine, Children's Hospital of Illinois; ‡Department of Internal Medicine and Center for Outcomes Research, University of Illinois College of Medicine at Peoria, Peoria, IL; §Department of Emergency Medicine, Shasta Regional Medical Center, Redding, CA; ∥Department of Pediatrics, University of Arkansas for Medical Sciences, ¶Injury Prevention Center, Arkansas Children's Hospital, Little Rock, AR; and **Department of Pediatrics, University of Alabama Medical Center, Children's of Alabama Hospital, Birmingham, AL.
• Pediatr Emerg Care. 2017 Oct 1; 33 (10): 663-669.

ObjectivesMotor vehicle crashes are the leading cause of childhood fatality, making use of properly installed child passenger restraint system (CRS) a public health priority. Motor vehicle crashes in rural environments are associated with increased injuries and fatalities, and overall CRS use tends to be lower compared with urban populations. However, it remains unclear if proper installation of car seats is lower in a rural population compared with a similar matched urban population.MethodsA multisite (Alabama, Arkansas, Illinois), observational, case-control study was performed using data from community child passenger safety checkup events in rural (economically and population-controlled) and urban locations. Data were matched to the primary child assessed in a vehicle, and stratified by age, site, and year with urban unscheduled CRS check data. All CRS checks were performed using nationally certified CRS technicians who used the best practice standards of the American Academy of Pediatrics and collected subject demographics, car seat misuse patterns, and interventions using identical definitions.ResultsFour hundred eighty-four CRS checks (242 rural and 242 urban) involving 603 total children from 3 states (Alabama, 43 [7%]; Arkansas, 442 [73%]; Illinois, 118 [20%]) were examined; of which, 86% had at least 1 documented CRS misuse. Child passenger restraint system misuse was more common in rural than urban locations (90.5% vs 82.6%; P = 0.01). Child passenger restraint system misuse was more common in rural children aged 4 to 8 years (90.3% vs 80.6%; P = 0.02).ConclusionsIn this multisite study, rural location was associated with higher CRS misuse. Child passenger restraint system education and resources that target rural populations specifically appear to be justified.

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