Examining Veterans' Experiences With In Vitro Fertilization Provided Under P.L. 114-223.

BACKGROUND: Until recently, the Department of Veterans Affairs (VA) medical benefits package has expressly excluded in vitro fertilization (IVF) services for Veterans experiencing fertility problems. However, P.L. 114-223 (2016) allows VHA to provide Assisted Reproductive Technology, including IVF, to certain eligible Veterans. Little is known regarding Veterans' experiences accessing IVF through VA Community Care contracts with IVF providers. OBJECTIVE: To examine Veterans' experiences with IVF services provided under the auspices of P.L. 114-223. RESEARCH DESIGN: Telephone or video interviews were conducted with male and female Veterans and opposite-sex spouses of Veterans who had been approved for IVF. Interviews were recorded, transcribed, and analyzed using content analysis techniques. Major themes and representative quotes were derived from the analyses. RESULTS: Ninety-six Veterans and 14 spouses participated in our interviews. Six major themes arose from these interviews, including (1) the need for improved communication regarding IVF benefits, (2) the need for expanded IVF benefits, (3) the lack of a comprehensive care coordination program, (4) poor access to IVF providers in some areas of the country, (5) special services needed for Veterans with spinal cord injuries, and (6) the IVF policy may be discriminatory in nature to single and LGBTQ Veterans. CONCLUSIONS: Many Veterans with service-connected conditions related to reproductive health have taken advantage of the IVF benefit, though limitations on these benefits have prevented other Veterans from taking advantage of the IVF benefit. Further attention needs to be paid to improving communication and coordination of IVF services with ongoing VA care and ensuring special populations, including those living in rural areas and Veterans with spinal cord injuries, have access to IVF services as needed.

Examining Pregnant Veterans' Acceptance and Beliefs Regarding the COVID-19 Vaccine.

BACKGROUND: Pregnant persons have received mixed messages regarding whether or not to receive COVID-19 vaccines as limited data are available regarding vaccine safety for pregnant and lactating persons and breastfeeding infants. OBJECTIVE: The aims of this study were to examine pregnant Veteran's acceptance of COVID-19 vaccines, along with perceptions and beliefs regarding vaccine safety and vaccine conspiracy beliefs. DESIGN AND PARTICIPANTS: We conducted a cross-sectional survey of pregnant Veterans enrolled in VA care who were taking part in an ongoing cohort study at 15 VA medical centers between January and May 2021. MAIN MEASURES: Pregnant Veterans were asked whether they had been offered the COVID-19 vaccine during pregnancy, and whether they chose to accept or refuse it. Additional questions focused on perceptions of COVID-19 vaccine safety and endorsements of vaccine knowledge and conspiracy beliefs. Logistic regression was utilized to examine predictors of acceptance of a vaccine during pregnancy. KEY RESULTS: Overall, 72 pregnant Veterans were offered a COVID-19 vaccine during pregnancy; over two-thirds (69%) opted not to receive a vaccine. Reasons for not receiving a vaccine included potential effects on the baby (64%), side effects for oneself (30%), and immunity from a past COVID-19 infection (12%). Those who received a vaccine had significantly greater vaccine knowledge and less belief in vaccine conspiracy theories. Greater knowledge of vaccines in general (aOR: 1.78; 95% CI: 1.2-2.6) and lower beliefs in vaccine conspiracies (aOR: 0.76; 95% CI: 0.6-0.9) were the strongest predictors of acceptance of a COVID-19 vaccine during pregnancy. CONCLUSIONS: Our study provides important insights regarding pregnant Veterans' decisions to accept the COVID-19 vaccine, and reasons why they may choose not to accept the vaccine. Given the high endorsement of vaccine conspiracy beliefs, trusted healthcare providers should have ongoing, open discussions about vaccine conspiracy beliefs and provide additional information to dispel these beliefs.

Understanding Women's Transitions from Military to Department of Veterans Affairs Care.

Background: Over the past two decades, increasing numbers of women have served in the military, with women now comprising 17.3% of active-duty personnel and 21.4% of National Guard and reserves. During military service, women often incur painful musculoskeletal (MSK) injuries related to carrying heavy loads and wearing ill-fitting gear. While women may receive initial care for these injuries under the auspices of the Department of Defense (DoD), these injuries often linger and further treatment in required as women transition to Department of Veterans Affairs (VA) care. However, little is known about this transition process, and whether women are given adequate information and support regarding how to access VA care after their military service has ended. Research Design: To better understand these issues, we interviewed 65 women veterans with military service-related MSK injuries about their transition from DoD to VA care. Results: Six major themes emerged from the interviews. Those themes were: (1) Military injuries are often related to ill-fitting gear or carrying heavy loads; (2) Stigma/discrimination related to military injuries; (3) Limited assistance with transition between DoD and VA to manage ongoing injuries and pain; (4) Women have a difficult time managing perceptions and expectations of their weight after military service; (5) Childcare is a substantial burden for veterans in self-care; and (6) veterans desire peer-support services to help them stay healthy. Conclusions: Based on these findings, DoD and VA should continue to work together to develop programs to educate and support women as they transition from military to VA care. Furthermore, VA should consider developing peer support programs for women Veterans who may require additional support to maintain health, especially among Veteran mothers who have complex family responsibilities that may limit their ability to focus on their own health.

Experiences and Perceptions of Maternal Autonomy and Racism Among BIPOC Veterans Receiving Cesarean Sections.

BACKGROUND: Previous studies of pregnant veterans enrolled in Department of Veterans Affairs (VA) care reveal high rates of cesarean sections among racial/ethnic minoritized groups, particularly in southern states. The purpose of this study was to better understand contributors to and veteran perceptions of maternal autonomy and racism among veterans receiving cesarean sections. METHODS: We conducted semi-structured interviews to understand perceptions of maternal autonomy and racism among 27 Black, Indigenous, People of Color (BIPOC) veterans who gave birth via cesarean section using VA maternity care benefits. RESULTS: Our study found that a substantial proportion (67%) of veterans had previous cesarean sections, ultimately placing them at risk for subsequent cesarean sections. More than 60% of veterans with a previous cesarean section requested a labor after cesarean (LAC) but were either refused by their provider or experienced complications that led to another cesarean section. Qualitative findings revealed the following: (1) differences in treatment by veterans' race/ethnicity may reduce maternal agency, (2) many veterans felt unheard and uninformed regarding birthing decisions, (3) access to VA-paid doula care may improve maternal agency for BIPOC veterans during labor and birth, and (4) BIPOC veterans face substantial challenges related to social determinants of health. CONCLUSION: Further research should examine veterans' perceptions of racism in obstetrical care, and the possibility of VA-financed doula care to provide additional labor support to BIPOC veterans.

Exploring the Experience of Pain and Pain Management for Pregnant and Postpartum Veterans With Chronic Musculoskeletal Pain.

BACKGROUND: To examine how veterans experience and treat pain during the perinatal period, we conducted a qualitative study to explore the experiences of pain, pain management, and facilitators and barriers to treatment among perinatal veterans. METHODS: We identified veterans who received care at 1 of 15 Veterans Health Administration (VHA) facilities across the United States and were enrolled in an ongoing cohort study. All participants gave birth to a newborn between March 2016 and June 2021 and met the inclusion criteria for having a prepregnancy pain-related musculoskeletal condition. We completed interviews with 30 veterans between November 2021 and January 2022. We used a framework approach to our qualitative analysis. RESULTS: Veterans in our sample were, on average, 31 years of age, married (80%), and white (47%). The most common type of pain diagnoses were back pain (93%) and joint disorders (73%). We identified the following major themes: 1) veteran experiences of pain during pregnancy, 2) challenges to pain care during the perinatal period, and 3) veteran recommendations for VHA perinatal pain care. Experiences of pain during pregnancy varied and several barriers to pain care were identified. Veterans suggested several ways the VHA could improve pain care during the perinatal period, including more training for VHA providers on perinatal pain care and greater complementary and integrative health coverage. CONCLUSIONS: Understanding the unique needs of pregnant veterans with chronic pain is important to provide high-quality care during the perinatal period. Veterans who participated in this study highlighted several areas where the VHA could improve pain management during pregnancy and postpartum.

A mixed-methods study of VA video connect utilization among veterans with diabetes experiencing housing instability during the pandemic.

Introduction: Prior to the coronavirus disease-2019 (COVID-19) pandemic the U.S. Department of Veterans Affairs (VA) had the largest telehealth program in the United States. The pandemic motivated providers within the VA to expand telehealth in effort to reduce disrupted care while mitigating risks. The pandemic provides a rare opportunity to examine how to better engage veterans experiencing housing instability (HI) in telehealth diabetes care. Methods: Mixed methods design to examine VA video connect (VVC) diabetes care utilization among veterans experiencing HI from March 1, 2019, to March 1, 2022, combining multivariable regression analyses of VA administrative data with semi-structured interviews. Study aims included: (a) examine changes in diabetes care delivery mode over the peri-pandemic timeframe; (b) identify sociodemographic and clinical characteristics associated with VVC care among veterans with HI; and (c) understand the facilitators and barriers of VVC utilization. Results: Totally, 5904 veterans were eligible for study analysis. Veterans who are female (OR: 1.63; 95% CI: 1.3, 2.0; p < 0.0001), self-identify as Hispanic (OR: 1.44; 95% CI: 1.1, 1.9; p = 0.02), are married (OR: 1.39; 95% CI: 1.2, 1.6; p < 0.0001), and are in VA priority group 1 (OR: 1.21; 95% CI 1.1, 1.4; p = 0.004) were more likely to use VVC the pandemic. Veterans of older age (OR: 0.97; 95% CI: 0.97, 0.98; p < .0001) and rural dwelling (OR: 0.85; 95% CI: 0.7, 1.2; p = 0.04), were less likely to use VVC. Thirteen VA providers and 15 veterans were interviewed. Veterans reported that decisions about using VVC were driven by limitations in in-person care availability, safety, and convenience. Discussion: Telehealth played an important role in providing veterans with HI access to diabetes care during the pandemic. Future interventions should seek to increase education and technology in effort to increase VVC uptake into routine diabetes care to ensure veterans' optimal and equitable access.

Using RE-AIM to examine implementation of a tele-nephrology program for veterans living in rural areas.

Introduction: Chronic kidney disease (CKD) and refractory hypertension (rHTN) are common, chronic conditions that affect 10%-16% of Veterans. Several small studies have suggested that tele-nephrology can deliver nephrology care effectively to rural Veterans. The purpose of this evaluation was to examine perceptions and experiences with this tele-nephrology program among spoke site staff and clinicians using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to guide our understanding of tele-nephrology implementation. Methods: We conducted semi-structured interviews with fourteen clinicians at five tele-nephrology spoke sites. We used content analysis to analyze the results using our RE-AIM framework. Results: Five major themes arose: (1) Active engagement of a centralized clinical champion was a key factor in early success of tele-nephrology program; (2) Transition from community-based nephrology to VA tele-nephrology was heralded as the most meaningful indicator of the effectiveness of the intervention; (3) Effective adoption strategies included bi-weekly training with Hub nephrology staff and engagement of a local renal champion; (4) Meeting the needs of Veterans through proper staffing during tele-nephrology examinations was a key priority in facility program implementation; and (5) Growing reliance on Hub nephrologists may give rise to insufficient availability of nephrology appointments in some Spoke sites. Discussion: This evaluation represents an important step forward as VA considers how to provide care to Veterans at facilities without VA specialty providers. The COVID-19 pandemic has drastically shifted options for Veterans, and increasingly, the VA is moving to shift care from community to VA via virtual care. Further research should examine how the VA manages potential problems related to access to virtual providers and examine Veteran perspectives on community in-person vs. virtual VA care.

Newborn Outcomes Among Veterans Utilizing VHA Maternity Benefits, 2016-2020.

INTRODUCTION: Public Law 111-163 Section 206 of the Caregivers and Veteran Omnibus Health Services Act amended the Veterans Health Administration's (VHA) medical benefits package to include 7 days of medical care for newborns delivered by Veterans. We examined the newborn outcomes among a cohort of women Veterans receiving VHA maternity benefits and care coordination. MATERIALS AND METHODS: We conducted a secondary analysis of phone interview data from Veterans enrolled in the COMFORT (Center for Maternal and Infant Outcomes Research in Translation) study 2016-2020. Multivariable regression estimated associations with newborn outcomes (preterm birth; low birthweight). RESULTS: During the study period, 829 infants were born to 811 Veterans. Mothers reported "excellent health" for 94% of infants. The prevalence of preterm birth was slightly higher in our cohort (11% vs. 10%), as were low birthweight (9%) deliveries, compared to the general population (8.28%). Additionally, 42% of infants in our cohort required follow-up care for non-routine health conditions; 11% were uninsured at 2 months of age. Adverse newborn outcomes were more common for mothers who were older in age, self-identified as non-white in race and/or of Hispanic ethnicity, had a diagnosis of posttraumatic stress disorder, or had gestational comorbidities. CONCLUSIONS: The current VHA maternity coverage appears to be an effective policy for ensuring the well-being and health care coverage for the majority of Veterans and their newborns in the first days of life, thereby reducing the risk of inadequate prenatal and neonatal care. Future research should examine costs associated with extending coverage to 14 days or longer, comparing those to the projected excess costs of neonatal health problems. VHA policy should continue to support expanding care and resources through the Maternity Care Coordinator model.

Coordinating women's preventive health care for rural veterans.

PURPOSE: As the number of women veterans receiving care from the Veterans Health Administration (VHA) continues to increase, so does the need to access gender-specific preventive health care services through the VHA. In rural areas, women veterans are the numeric minority, so many preventive screenings are performed outside of the VA by community providers. As the numbers of veterans utilizing both VHA and non-VHA providers for their preventive care continue to increase, so does the need to coordinate this care. This research examines the role of the Women Veterans' Care Coordinator (WVCC) at rural facilities and their perceptions of coordinating preventive care. METHODS: Between March and July 2019, semi-structured telephone interviews were conducted with WVCCs at 26 rural VA facilities. Each interview was digitally recorded and transcribed verbatim. Transcripts were loaded into Atlas.ti for further analysis. Once the codes were refined, the investigators coded the 26 interviews independently and conferred to achieve consensus on the underlying themes. FINDINGS: Five themes arose from the WVCC interviews: (1) Rural women veterans have varying needs of coordination; (2) Fragmented communication between the VA and non-VA care settings hinders effective coordination; (3) Difficulties in prioritizing rural care coordination; (4) Care coordination impacts patient care; and (5) WVCC recommendations to improve rural care coordination. CONCLUSIONS: The recent addition of WVCCs to rural facilities has expanded the VA's reach to veterans living in the most rural areas. As a result, many of these women are now receiving timely, quality, and coordinated health care.

Veterans' Perinatal Care and Mental Health Experiences During the COVID-19 Pandemic: An Examination of the Role of Prior Trauma and Pandemic-Related Stressors.

Background: Many pregnant and postpartum Veterans have experienced multiple lifetime traumas, including military sexual trauma, intimate partner violence, and combat trauma. These women may be particularly vulnerable to increased post-traumatic stress disorder and other mental health problems following additional trauma exposures or stressful events, such as Coronavirus disease 2019 (COVID-19). This study sought to examine the impact of prior trauma exposures on the lived experience of pregnant and postpartum Veterans during the COVID-19 pandemic. Materials and Methods: Pregnant Veterans at 15 VA medical centers were surveyed at 20 weeks of pregnancy and 3 months postpartum asked about their COVID-19-related perinatal and mental health experiences, as well as the stressors that impacted them as a result of the COVID-19 pandemic. Results: Overall, 111 women Veterans completed both the pregnancy and postpartum surveys that included COVID-19 items. Sixty percent of our sample had experienced at least one potentially traumatic lifetime event, with 22% of our sample experiencing two or more of the included exposures. Women with a trauma history had 3.5 times increased odds of reporting their mental health as "much worse" compared to before the COVID-19 pandemic (95% confidence interval [CI]: 1.06-11.75) and were more likely to report that COVID-19 negatively affected their mental or emotional health "a lot" compared with women without a trauma history (odds ratio: 8.5; 95% CI: 1.93-37.48). Conclusions: COVID-19 has had a significant impact on pregnant and postpartum Veterans' mental health. Obstetricians should consider strategies to ensure women have access to mental health care during pregnancy, especially as the COVID-19 pandemic continues. Hospitals should also consider the importance of labor support companions during the COVID-19 pandemic and examine adjusting policies to allow for at least one labor support companion during labor and delivery.

Quality and Value of Health Care in the Veterans Health Administration: A Qualitative Study.

Background The attitudes of Department of Veterans Affairs ( VA ) cardiovascular clinicians toward the VA 's quality-of-care processes, clinical outcomes measures, and healthcare value are not well understood. Methods and Results Semistructured telephone interviews were conducted with cardiovascular healthcare providers (n=31) at VA hospitals that were previously identified as high or low performers in terms of healthcare value. The interviews focused on VA providers' experiences with measures of processes, outcomes, and value (ie, costs relative to outcomes) of cardiovascular care. Most providers were aware of process-of-care measurements, received regular feedback generated from those data, and used that feedback to change their practices. Fewer respondents reported clinical outcomes measures influencing their practice, and virtually no participants used value data to inform their practice, although several described administrative barriers limiting high-cost care. Providers also expressed general enthusiasm for the VA 's quality measurement/improvement efforts, with relatively few criticisms about the workload or opportunity costs inherent in clinical performance data collection. There were no material differences in the responses of employees of low-performing versus high-performing VA medical centers. Conclusions Regardless of their medical center's healthcare value performance, most VA cardiovascular providers used feedback from process-of-care data to inform their practice. However, clinical outcomes data were used more rarely, and value-of-care data were almost never used. The limited use of outcomes data to inform healthcare practice raises concern that healthcare outcomes may have insufficient influence, whereas the lack of value data influencing cardiovascular care practices may perpetuate inefficiencies in resource use.

Association Between Spending and Survival of Chronic Heart Failure Across Veterans Affairs Medical Centers.

Importance: The US Department of Veterans Affairs (VA) provides health care to more than 2 000 000 veterans with chronic cardiovascular disease, yet little is known about how expenditures vary across VA Medical Centers (VAMCs), or whether VAMCs with greater health expenditures are associated with better health outcomes. Objectives: To compare expenditures for patients with chronic heart failure (CHF) across the nation's VAMCs and examine the association between health care spending and survival. Design, Setting, and Participants: Retrospective cohort study using existing administrative data sets from the VA's Corporate Data Warehouse and each veteran's Medicare enrollment information and claims history for fee-for-service clinicians outside of the VA from 265 714 patients diagnosed with CHF between April 1, 2010, and December 31, 2013, who received care at any of 138 VAMCs or affiliated outpatient clinics nationwide. Patients were followed up through September 30, 2014. Data were analyzed from April 1, 2010, through September 30, 2014. Main Outcomes and Measures: Main outcomes were patient deaths per calendar quarter and aggregate VA costs per calendar quarter. Hierarchical generalized linear models with hospital-level random effects were estimated to calculate both risk-standardized annual health care expenditures and risk-standardized annual survival rates for veterans with CHF at each VAMC. The association between VAMC-level expenditures and survival was then modeled using local and linear regression. Results: Of the 265 714 patients included, 261 132 (98.7%) were male; 224 353 (84.4%) were white; 41 110 (15.5%) were black, Asian, Pacific Islander, American Indian, or Alaskan Native; and 251 (0.1%) did not report race. Mean (SD) age of the patients included was 74 (10) years. Across 138 VAMCs, mean (95% CI) annual expenditures for veterans with CHF varied from $21 300 ($20 300-$22 400) to $52 800 ($49 400-$54 300) per patient, whereas annual survival varied between 81.4% to 88.9%. There was a modest V-shaped association between spending and survival such that adjusted survival was 1.7 percentage points higher at the minimum level of spending compared with the inflection point of $34 100 per year (P = .001) and 1.9 percentage points higher at the maximum level of spending compared with the inflection point (P = .006). Conclusions and Relevance: Despite marked differences in mean annual expenditures per veteran, only a modest association was found between CHF spending and survival at the VAMC level, with slightly higher survival observed at the extremes of the spending range. Hospitals with high expenditures may be less efficient than their peer institutions in producing optimal health outcomes.

Outcomes of Care for Ischemic Heart Disease and Chronic Heart Failure in the Veterans Health Administration.

Importance: The Department of Veterans Affairs (VA) operates a nationwide system of hospitals and hospital-affiliated clinics, providing health care to more than 2 million veterans with cardiovascular disease. While data permitting hospital comparisons of the outcomes of acute cardiovascular care (eg, myocardial infarction) are publicly available, little is known about variation across VA medical centers (VAMCs) in outcomes of care for populations of patients with chronic, high-risk cardiovascular conditions. Objective: To determine whether there are substantial differences in cardiovascular outcomes across VAMCs. Design, Setting, and Participants: Retrospective cohort study comprising 138 VA hospitals and each hospital's affiliated outpatient clinics. Patients were identified who received VA inpatient or outpatient care between 2010 and 2014. Separate cohorts were constructed for patients diagnosed as having either ischemic heart disease (IHD) or chronic heart failure (CHF). The data were analyzed between June 24, 2015, and November 21, 2017. Exposures: Hierarchical linear models with VAMC-level random effects were estimated to compare risk-standardized mortality rates for IHD and for CHF across 138 VAMCs. Mortality estimates were risk standardized using a wide array of patient-level covariates derived from both VA and Medicare health care encounters. Main Outcomes and Measures: All-cause mortality. Results: The cohorts comprised 930 079 veterans with IHD and 348 015 veterans with CHF; both cohorts had a mean age of 77 years and were predominantly white (IHD, n = 822 665 [89%] and CHF, n = 287 871 [83%]) and male (IHD, n = 916 684 [99%] and CHF n = 341 352 [98%]). The VA-wide crude annual mortality rate was 7.4% for IHD and 14.5% for CHF. For IHD, VAMCs' risk-standardized mortality varied from 5.5% (95% CI, 5.2%-5.7%) to 9.4% (95% CI, 9.0%-9.9%) (P < .001 for the difference). For CHF, VAMCs' risk-standardized mortality varied from 11.1% (95% CI, 10.3%-12.1%) to 18.9% (95% CI, 18.3%-19.5%) (P < .001 for the difference). Twenty-nine VAMCs had IHD mortality rates that significantly exceeded the national mean, while 35 VAMCs had CHF mortality rates that significantly exceeded the national mean. Veterans Affairs medical centers' mortality rates among their IHD and CHF populations were not associated with 30-day mortality rates for myocardial infarction (R2 = 0.01; P = .35) and weakly associated with hospitalized heart failure 30-day mortality (R2 = 0.16; P < .001) and the VA's star rating system (R2 = 0.06; P = .005). Conclusions and Relevance: Risk-standardized mortality rates for IHD and CHF varied widely across the VA health system, and this variation was not well explained by differences in demographics or comorbidities. This variation may signal substantial differences in the quality of cardiovascular care between VAMCs.

Are mHealth Interventions to Improve Child Restraint System Installation of Value? A Mixed Methods Study of Parents.

Childhood death from vehicle crashes and the delivery of information about proper child restraint systems (CRS) use continues to be a critical public health issue. Safe Seat, a sequential, mixed-methods study identified gaps in parental knowledge about and perceived challenges in the use of appropriate CRS and insights into the preferences of various technological approaches to deliver CRS education. Focus groups (eight groups with 21 participants) and a quantitative national survey (N = 1251) using MTurk were conducted. Although there were differences in the age, racial/ethnic background, and educational level between the focus group participants and the national sample, there was a great deal of consistency in the need for more timely and personalized information about CRS. The majority of parents did not utilize car seat check professionals although they expressed interest in and lack of knowledge about how to access these resources. Although there was some interest in an app that would be personalized and able to push just-in-time content (e.g., new guidelines, location and times of car seat checks), content that has sporadic relevance (e.g., initial installation) seemed more appropriate for a website. Stakeholder input is critical to guide the development and delivery of acceptable and useful child safety education.

Reasons for Child Passenger Nonrestraint in Motor Vehicles.

OBJECTIVE: Although child passenger restraint use in motor vehicles has increased, there is an important minority of children who remain unrestrained. The goal of this study was to identify the frequency of and under what circumstances parents keep their children unrestrained. METHODS: A cross-sectional, online survey was distributed to parents and caregivers of children 10 years old and younger. Survey participants were asked about child restraint practices, including frequency of and reasons for nonuse of restraints. Parents were specifically asked how acceptable it would be to keep their child unrestrained in certain situations. RESULTS: One thousand two hundred eighty-five parents and guardians responded to the survey and 1,002 completed it; 23.8% (95% confidence interval [CI], 21.3-26.6%) of respondents said they had driven with their child not fully restrained on at least one occasion. Approximately 1 in 5 parents strongly or somewhat agreed that it would be acceptable to keep their child unrestrained in certain situations, including a short drive, in a rush, an inadequate number of restraints, riding in a taxi, if somebody was holding the child, and as a reward for a child. Parents were more likely to agree that it was acceptable to keep their child unrestrained under nearly all circumstances listed if they were male, ages 18-29, with a graduate school education, in the $100,000+ income bracket, or Latino. CONCLUSIONS: There are certain situations for which parents find it acceptable to leave their children unrestrained. This has implications for targeted child passenger safety efforts designed to maximize consistent restraint use.