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Motorization growth worldwide is increasing children’s exposure to motor vehicle occupant crash injury. The use of child safety seats and seat belts, as appropriate for a child’s age and development, is one of the most effective ways to reduce child occupant injury in a crash. However, child safety seat use varies throughout the world.Compare children’s occupant protection use, driver knowledge, and barriers to use in three countries: one with a comprehensive policy (Iowa City, United States), one with a partial policy (Cluj-Napoca, Romania) and one with no policy (Shantou, China) at the time of data collection.Using a standardized protocol, child occupant protection use was observed and driver surveys were conducted. More than 7 000 children in vehicles were observed, and of these more than 65% of drivers were interviewed.For children aged 0 to 3, who should be in a safety seat, 95.9% of children in the US were properly restrained, compared with 49.6% in Romania and 0.1% in China. For children aged 4–12, who should be in booster seats, 65% of children in the US, 34.6% in Romania, and 1.5% of children in China were properly restrained. For children aged 13–17, 82.7% of children in the US, 65.0% in Romania, and 25.2% in China were wearing seat belts. Driver seat belt use was 90.6% in the US, 66.8% in Romania, and 58.3% in China. In China, 26.8% of drivers reported that they did not know about safety seats. In Romania, 68.4% were aware that some type of law was in place. Barriers were similar and included lack of knowledge or awareness, expense, and choosing not to use one.Prevalence of child occupant restraint was highly correlated with the country’s policy status, although barriers to use were similar.