In the early 2000s, the Northwest Tribal Epidemiology Center (The EpiCenter) noticed a growing disparity in motor vehicle fatalities for American Indian and Alaska Native children. We wanted to investigate whether low rates of child safety seat use could help explain the disparity.

In 2003, with funding from the Indian Health Service’s Native American Research Centers for Health (NARCH, grant 1U269400013-01), six Northwest tribes conducted a child safety seat survey. We found that child safety seat use ranged from 25% to 55% by tribe. Forty percent of children were completely unrestrained in the vehicle, which was much higher than the 12% of unrestrained children in the general population in these same states. We concluded that culturally-appropriate efforts were needed to address child restraint use in the Northwest tribes. At the tribes’ request, the EpiCenter pursued funding for child safety seat interventions.


 In 2003 we found that:


of native children were correctly restrained in their vehicles

compared to


of children in the general population

In 2008, we received funding from the National Institute on Minority Health and Health Disparities (grant 5 R24 MD002763) to use a community-based participatory research approach to develop and test community-specific interventions to increase child safety seat use in these same six Northwest Tribes. The tribes named the project Native Children Always Ride Safe (Native CARS).

All six tribes did intervention activities, but in a staggered design. Three tribes designed and implemented interventions from 2009-2011 and three tribes did so from 2011-2013. This gave us an evaluation time point in 2011 to compare child safety seat use in intervention tribes to tribes that had not yet implemented interventions. We evaluated child safety seat use again in 2013 to see if the interventions had a lasting impact in the first group and to see if child safety seat use increased in the second group of tribes.

Tribes planned their intervention efforts according to the data they collected from their community from surveys, interviews, and focus groups. Intervention activities included media campaigns, health education, car seat programs, getting child passenger safety technicians trained, community outreach, and even changing tribal policies or passing a tribal child passenger safety law.

By 2011, the percentage of kids riding in an age- and size-appropriate restraint increased by 50% in tribes that had implemented interventions, compared to an 11% increase in those that had not yet conducted child safety seat activities. In 2013, the increases we saw in the first group of intervention tribes were mostly sustained, and the percentage of completely unrestrained children continued to decrease. Round 2 tribes also saw an increase in proper child restraint after their intervention activities.

Because Native CARS was successful, we are sharing our process and intervention activities through the Native CARS Atlas. We hope that other tribes will find ideas and resources here to help increase child passenger safety in their communities.