American Indians and Alaska Natives face many health disparities related to personal behavior. If the behavior changes, then the health disparity can be reduced or eliminated.


One of the biggest and saddest Native health disparities involves car crashes. Native children are almost twice as likely as children of other races to die in a motor vehicle crash. This is because Native children are less likely than other children to wear seatbelts or to sit in car safety seats when they ride in cars.


Working with local tribes, Dr. Jodi Lapidus of the Northwest Portland Area Indian Health Board is doing something to change this situation. Her organization is directed by delegates from all 43 federally recognized tribes in Oregon, Washington, and Idaho.


In 2003, Dr. Lapidus’ team conducted a survey of child restraint in six tribal communities – two in each of the three states covered by the Health Board. They found that most Native children in these communities rode either unrestrained or improperly restrained.

True in Carseat

According to the National Highway Transportation Safety Administration, these are appropriate restraints for children:

  • rear-facing infant seats for babies before their first or second birthday (age guidelines vary)
  • forward-facing child seats for children between 1 and 4 years who weigh less than 40 pounds
  • booster seats for children between 4 and 7 years who weigh 40 to 80 pounds
  • adult lap and shoulder belts for children aged 8 and older


When Dr. Lapidus’ team presented their results to the tribes, tribal leadership approved an intervention: Native Children Always Ride Safe (Native CARS). Its goal is to improve the use of car seats, seatbelts, and other restraints by Native families. All six tribes have worked on the design and delivery of the intervention.


To establish a baseline for data collection, Dr. Lapidus’ team revisited the same six communities in 2009 to repeat the observations made in 2003. Their results are reported in a recent issue of the American Journal of Public Health (see link below).


In each reservation or tribal community, the researchers visited the parking lots of gas stations, mini marts, day care centers, schools, and other places where children could be seen riding in cars. They approached cars and asked the driver if he or she would answer a few survey questions. The study was limited to Native people.


Among eligible drivers, a large majority agreed to participate. Among drivers who participated, 61% were wearing seatbelts. However, among drivers who declined to participate, only 32% were wearing seatbelts. The average age of participating drivers was 34 years, and the average driving time to the driver’s home was 12 minutes.


The 2009 survey returned interesting results. The use of restraints for children aged 12 and under had improved since 2003, even without any interventions. In total, 71% of Native children rode with some kind of restraint. However, this improved rate was still much lower than the rate of 93% for non-Native children surveyed in the same geographic region in 2008. Even among Native children who rode with restraint, many were incorrectly restrained. Improper restraint includes using a restraint that doesn’t fit, or riding with a restraint in the front seat when space is available in the back seat.


Child-Car-Safety - state of MarylandFour steps for child restraint in cars, based on guidelines from the National Highway Transportation Safety Administration. 1) Babies younger than 2 years; 2) children aged 1-4 years; 3) children aged 4-7 years; 4) children aged 8 and up.


Overall, only 49% of Native children were observed with the recommended restraint, even in 2009. The researchers identified the following risk factors for improper child restraint:

  • Driver is not wearing a seatbelt.
  • Vehicle is a truck instead of a car.
  • Vehicle is only 5 minutes’ driving time, or less, from home.
  • Driver is someone other than the child’s parent (for example, a grandparent who is unfamiliar with new safety guidelines or whose vehicle doesn’t have a child safety seat).
  • Location has tribal laws on child restraint that are weaker than state laws.


Several other findings are notable. First, among all children, babies younger than one year were the mostly likely to be correctly restrained. Second, children aged six to seven years were the least likely to be correctly restrained. This was usually because they were wearing adult seat belts that were too big for them. Third, between 2003 and 2009, Oregon, Washington, and Idaho adopted stricter state laws on child restraint. However, the laws in Idaho are less strict than the laws in Oregon and Washington. In addition, on reservations where tribal laws instead of state laws govern traffic safety, the tribal laws are less strict than the state laws.


Most drivers in this study said they did not know anyone who had ever received a ticket for improper use, or non-use, of child restraints. Along with the data on risk factors, this result suggests that laws on child restraint should be enforced more strongly. It also indicates the need for wider public awareness of how to use child restraints correctly.


The Native CARS study is still in progress. We look forward to hearing more from the researchers and participating tribes on this important intervention.


Original article: Lapidus JA, Smith NH, Lutz T, Ebel BE; Native CARS Study Group. Trends and correlates of child passenger restraint use in 6 Northwest tribes: the Native Children Always Ride Safe (Native CARS) project. Am J Public Health 2013;103(2):355-61. doi: 10.2105/AJPH.2012.300834.
Abstract at
Northwest Portland Area Indian Health Board:
Northwest Tribal Epidemiology Center (the EpiCenter):
Harborview Injury Prevention & Research Center: