|INCREASING TEEN SAFETY BELT USE|
B. Literature Review
Two hundred and sixty-nine documents were reviewed for this project. These included peer-reviewed journal articles, non-reviewed articles, NHTSA reports, other Federal reports, State reports, reports from private foundations, newspaper articles, online articles, and other various sources of information such as intervention guidebooks, instructional videos, educational pamphlets, and program brochures. NHTSA reports constituted the majority of documents in this review. These ranged from one-page fact sheets to comprehensive reviews of empirical studies.
A wide range of sources was used in an attempt to gather a thorough account of the prevalence of teen-focused safety belt programs. Results of the review indicate that teen-specific safety belt programs are relatively scarce, and empirical evaluations of some programs are lacking. Despite the paucity of these programs, some have been implemented and their success has been empirically documented. Documents that contain information regarding these empirically evaluated programs constitute the first of six categories of information that were derived from the review. The categories will be discussed in order of ascending relevance and importance to this project.
Twenty-one documents were found within this first category established for the review; that is, discussing safety belt programs specifically targeted toward teenage drivers and providing at least some evidence of program effectiveness.
McCartt and Shabanova114 examined the effects of primary safety belt laws on the safety belt use of teenagers. Primary laws (also known as standard safety belt laws) allow police officers to pull over and ticket drivers solely for a safety belt violation, while secondary laws assert that police can ticket drivers for belt violations only after pulling them over for another (primary) offense such as speeding or running a red light. McCartt and Shabanova reviewed nationwide crash data and found that teens 16 to 19 used safety belts to a higher degree in States with primary belt laws. Through regression analysis, they also found that one of the strongest predictors of teen safety belt use was whether the State had a primary enforcement law. This suggests that one promising approach to increasing safety belt use among teen drivers is through more stringent legislation.
A study by Preusser, Williams, and Lund134 found that New York’s primary safety belt law, when first enacted, increased observed safety belt use among teen drivers in high school parking lots. The increase was dramatic, from 14 to 63 percent, indicating that mandatory safety belt laws have been very successful at increasing the safety belt use of teenagers, not just adult drivers.
NHTSA provided a report on a comprehensive program in Minnesota titled Teens Driving Safe, which also has been shown to effectively increase safety belt use among teen drivers.267 This program used both enforcement and education strategies. Analysis of crash data, police records, and observational surveys indicated that the program increased 16-18-year-old teens’ safety belt use from 74 to 78 percent. This program is described in more detail later in this report in the section titled “Review of Four State Programs.”
A comprehensive teen driving safety program called MAKUS was implemented in Chattanooga, Tennessee. 42 The acronym stands for “Michael Appleby Keeping Us Safe.” The program, named after a teenager who was killed in a car crash, incorporates educational approaches and involvement from school administrations, parents, and students. Some activities involved within the program are units on driving safety within high-school physics and wellness classes, safety belt checks, rewards in the form of food coupons for safety belt compliance, and a mentorship program in which high school upperclassmen mentor younger students about driving safety. The document that was reviewed reported a 95 percent safety belt compliance rate after the program was implemented, which was “well above the national average for adults, and more than double the rate for teens”.
Another comprehensive program in Spokane, Washington, titled Driving for Life, was shown to be an effective intervention strategy as well. 257 This program combined education and awareness activities, strict enforcement, media efforts, peer education, and community involvement. The increased enforcement led to more citations issued for safety belt violations, but more importantly, observed safety belt use increased by 10 to 16 percent at three area high schools. Further, self-reported belt use of “always” using a safety belt increased from 46 to 71 percent. This project is also described in more detail later in this report.
A program implemented in Illinois, called Operation Cool, also used a comprehensive approach. Operation Cool used incentive-based contests, safety belt contracts, education, and normative feedback to increase the safety belt use of high school students.228 The program increased observed teen safety belt use from 55 to 70 percent, and showed rates of up to 90 percent in many schools.
In Nebraska, the Youth on the Move program242 and the Holt County Citizens for Safe Driving program252 both reported increased safety belt use among teens. The Youth on the Move program included youth-initiated safety belt checks, safety messages, incentives, visual reminders, and drug-free parties. Results showed an increase in observed safety belt use from 40.5 to 49.1 percent. A goal of the Holt County comprehensive traffic safety program was to increase safety belt use of high-school drivers. Observational surveys showed an increase in safety belt use from 21 to 31 percent.
In Illinois, Operation SCORE (Student Concentrated Occupant Restraint Efforts) 213 included a zero-tolerance enforcement and an educational component. Observational surveys showed that safety belt use increased from an average of 43 percent to as much as 70 percent in some high schools.
An educational project titled “Highways or Dieways” in Minnesota was created as a component of the Teen Occupant Protection Program.117 This project included police presentations at high schools which provided teens with traffic safety facts, gave rewards to drivers observed wearing safety belts, conveyed personal stories about traffic accidents, and provided a rollover simulator to educate teens on the dynamics of traffic crashes. Short-term analysis revealed that, on the day after the program, safety belt use increased by 18.6 percent, and a one-month follow-up showed a sustained 9.3 percent increase over the baseline rate.
Also in Minnesota, an educational program titled Operation Educate Teens effectively increased observed safety belt use among teens 15 to 18 years old by 19 percent. 251 This program encouraged teens to conduct educational activities that increased safety belt use among their peers. Analysis of crash data indicated that teen crash rates also declined after the program was implemented.
A peer-led educational campaign in Soda Springs, Idaho, aimed to reduce teen impaired driving and increase teen safety belt use. 237 The program also included a safety belt promotion contest. Observational surveys showed a substantial increase in teen (15–19) safety belt use, from 27 to 71 percent.
North Carolina created educational youth safety programs to increase teens’ safety belt use rate,199 awarding grants to schools participating in peer-led educational campaigns. The student-led awareness activities were successful in increasing safety belt use rates by 22 percent in 1993 (coincident with their first CIOT program), 14 percent in 1994, and 9 percent in 1996.
The Buckle Down and Buckle Up educational and motivational program in South Carolina increased the safety belt use of drivers younger than 21.231 This program incorporated visual displays of the number of teen fatalities (such as a “ribbon tree” hung with ribbons representing lives lost in traffic accidents), to remind students of traffic safety issues. The program increased teen safety belt use by 11.6 percent, although the method for obtaining this figure was not specified within the document.
The St. Lucie County Youth Traffic Safety Program in Florida was an educational campaign designed to increase awareness of the dangers of driving while impaired and to increase teen safety belt use.195 This campaign included several programs such as “Strides for Safety,” “Ghost Out,” “Prom Promise,” “Buckle Up America!,” and “Take the Lead.” Although the observational surveys “indicated a marked increase in the use of safety belts by middle and high school students…,” no statistics regarding the effectiveness of the program were included.
Nebraska created an educational Youth Driver Training Program encouraging parental involvement to increase safe driving among teens.230 Although the results were modest at best, self-reports showed that students who “always” wear their safety belts increased from 34.4 to 36.5 percent, and those who “never” wear their safety belts dropped from 17.1 to 14.5 percent.
A program called “Checkpoints” in Connecticut promoted parental management of teen driving behaviors.146 This program targeted parents with persuasive messages and educational materials to influence them to adopt driving restrictions for their teens. The program included videos, newsletters, and other materials, and also included a behavioral contract for parents and teens to sign. Although no empirical evidence was provided regarding safety belt use specifically, Simons-Morton, et al., 146 cite previous research showing that more frequent parental supervision is associated with a higher likelihood of teen safety belt use. Further, they offer evidence that this program increased parental supervision of teen driving. The National Institutes of Health124 also found that the Checkpoints program reduces teens’ risky driving behaviors.
A program implemented in Maryland to increase safety belt use among the students evoked a healthy competition between five area high schools. The “Battle of the Belts” program also included an educational component, and increased student drivers’ safety belt use by 5.8 percent and student occupants’ belt use by 10.4 percent.216
In Indiana, a youth-led intervention program created by the South Decatur Safety Group showed some success. 188 This program encouraged teens to work together to design a safe driving promotion program with the goal of changing fellow students’ driving behaviors and attitudes. The document that was reviewed did not specify what intervention strategies were involved with the promotion programs, but it did state that observational surveys showed an increase in safety belt use from 32 to 50 percent.
Johnston, Rivara, Droesch, Dunn, and Copass 94 assessed the effectiveness of Behavior Change Counseling (BCC) in reducing risky behaviors among adolescents. Counseling was provided to teens following an accident that led to an emergency room visit. While at the emergency room, young people 12 to 20 were provided with a brief counseling session intended to change risky behavior. One behavior addressed within the counseling session was safety belt use, and the researchers found that the counseling was effective in increasing self-reported safety belt use later on.
Other research indicated that economic incentives could prove useful in promoting safety belt use. In a study by Campbell, Hunter, and Stutts, 20 student drivers who wore safety belts were given coupons worth five dollars in North Carolina high school parking lots. The drivers were also entered into a lottery for $300. These incentives coincided with an educational campaign. This combined intervention raised observed belt use from 21 to 55 percent. Follow-up observations showed a slip to 36 percent, although this was still above pretest baseline levels.
This category included documents that provided evidence for the effectiveness of safety belt programs in general that could be applied to teens, or evaluated in reference to teens. The documents included information on overarching strategies that were applied to everyone—including teens—and strategies targeted toward other groups that could be applied to teens. This was the most abundant category, with over 45 documents describing effective safety belt interventions. Future research could apply these interventions to teens, or focus analyses on teens, to determine the effects.
Our review of the literature indicated that the most empirically supported safety belt promotion strategy is the passage of primary safety belt laws. Although little research has examined the direct effect these laws have on teens (see McCartt and Shabanova114 for an exception), an abundance of research has indicated a more general effectiveness of primary laws. Although detailed descriptions of the specific studies and their findings are beyond the scope and purpose of this paper, a brief listing of the reviewed documents is presented.
Engstrom, Gregersen, Hernetkoski, Keskinen, and Nyberg, 40 the Center for Disease Control and Prevention, 25 and Dihn-Zarr, et al., 32 have conducted their own reviews, each of which concluded that primary safety belt laws effectively increase general safety belt use and are more effective than secondary laws.
Other research has empirically demonstrated the effectiveness of primary laws on safety belt use with several methodologies, including:
Some reviewed documents cited evidence from previous research when asserting the effectiveness of primary laws.67 126 258 6 Other sources presented statistics indicating that primary laws are effective, and more effective than secondary laws, but the method for arriving at the given statistics was not provided. 126 266 256
Another strategy demonstrated to have an impact on safety belt use was enhanced enforcement. Again, a detailed description of the studies on enforcement is outside of the scope of this report, but a brief mention of the reviewed documents is appropriate.
The previously cited reviews by Engstrom, et. al., 40 the CDC, 25 and Dihn-Zarr, et. al., 32 offer conclusions regarding enforcement strategies in addition to their primary law conclusions. These researchers determined that enhanced enforcement is effective in increasing overall safety belt use.
Several enforcement strategies have been examined and shown to be effective in the documents reviewed for this project. These strategies include:
The methods used to investigate these enforcement programs included:
Another strategy to increase safety belt use in general incorporates in-car technology to prompt drivers to buckle their safety belts. Ford Motor Company developed a new sound-and-light reminder system with a longer duration, which is more effective than the current brief reminder systems that are standard in most vehicles. 166 The cited document that was reviewed stated that the new Ford system increased safety belt use by 7 percent, although it is unclear how this figure was obtained. Other research by Williams and Wells183 used interviews and showed that 46 percent of individuals reported that this new reminder system increased their safety belt use. Further, reactions to the new system were positive, with 78 percent of respondents indicating that they liked the system.
Other safety belt promotion strategies that have gained some empirical support are:
The third category of documents reviewed included articles describing safety belt interventions tailored toward teenagers. These articles, however, did not provide evidence of the programs’ effectiveness; thus, further investigation would be necessary to evaluate the programs’ value. Twenty-seven documents that were reviewed fit this category.
The University of Michigan Transportation Research Institute171 evaluated Streetwise, a teen driving safety intervention in the form of a video game. Although no data was provided, the authors stated that after playing the game, teens 15 to 17 were more likely to report wearing their safety belts. Also, teens in focus groups reported that they liked the game and found it to be helpful.
Another qualitative, focus-group study184 suggested that advertising campaigns containing realism, visual consequences, and peer involvement would be most effective in encouraging safety belt use among teens. Teenagers 15 to 19 in the focus groups said that they disliked cartoonish ads because they do not deal with the issue seriously enough. The results from the focus groups also suggest that primary belt laws with strict enforcement are an effective strategy to increase teen belt use.
Ferguson48 reviewed literature on GDL laws to determine the impact on teen risky behaviors. The author suggests that GDL programs could increase teen safety belt use, but did not give evidence of this effect. The author suggests that passing and enforcing primary laws may be the best way to increase teen belt use (see also McCartt and Shabanova114 as mentioned earlier).
A news article156 described a new electronic device that, when installed in motor vehicles, continuously monitors teen driving behaviors and gives corrective feedback to the teen driver. The device detects speeding, aggressive driving, safety belt use, and unsafe backing. It also acts as a tracking device for parents. There is no evidence provided about its effectiveness in increasing safety belt use.
Volkswagen of America, Inc., issued a press release describing its youth safety program called “Fasten Your Seat Belt… Go Far!”173 The program includes educational kits for teachers, contests for students to create their own television advertisements, and substantial rewards for contest winners. No evidence of the program’s effectiveness was provided.
A traffic safety project titled Buckle Up or Eat Glass was created by Farm Safety 4 Just Kids.45 This project targeted young drivers and passengers in rural communities to increase their awareness of roadway hazards and also increase their safety belt use. The project included educational programs, safety belt checkups, radio public service announcements, news releases, and posters. The description of the project provided by Farm Safety 4 Just Kids lists post-intervention rates of teen safety belt use across several States, but no pretest or comparison group rates are provided; thus the effectiveness of the program remains uncertain.
A flyer44 produced by the Family, Career, and Community Leaders of America provides a brief description of their FACTS program (Families Acting for Community Traffic Safety). This is a youth peer-education program with some projects that promote safety belt use. No evidence of the program’s effectiveness was included.
The Network of Employers for Traffic Safety created a guidebook127 for parents to help them teach and guide their teenagers to drive safely. “The Novice Driver’s Roadmap: A Guide for Parents” addresses safety belt issues and includes a behavioral contract for parents and teens to sign. A promise to use a safety belt is part of the behavioral contract. The guidebook states that it has been reviewed by experts and field tested to determine that it is effective, but no evidence or references are provided.
A grant report for NHTSA described the Frederick County Teen Safe Driving Initiative.249 This program’s purpose was to increase safety belt use and decrease underage drinking and impaired driving among 15- to 20-year-olds in Frederick County, Maryland. Strategies included increased enforcement, targeted enforcement operations, community consciousness interventions, media involvement and education, and interactive youth involvement. The report suggested, qualitatively, that the program had positive outcomes, but no empirical evidence was provided. Further details on this report can be found in the section titled “Review of Four Community Demonstration Programs Aimed at Teens” included later in the report.
The American School Health Association described some teen safety belt intervention strategies in a brief informational pamphlet.2 These strategies addressed social norms, provided interpersonal skills training, encouraged youth collaboration in safety belt promotion projects, addressed the faulty logic behind safety belt nonuse, and integrated traffic safety materials in school health education. Although the document provided no evidence of effectiveness, it cited studies investigating the effects of social norm interventions in general.
Jack and Jill of America created several programs92 addressing health behaviors of teens and children. Some teen programs specifically target the issue of safety belt use. One such program includes a safety belt pledge, but no evidence of the effectiveness of these programs was provided within the reviewed document.
The National Organization for Youth Safety implemented a program called Speak Out and Make NOYS125 that included several teen-initiated projects promoting healthy teen behaviors, some of which are safety-belt-specific. The NOYS items reviewed for this project included a project manual, a project organizer, and a video. None of these items included evidence of the projects’ effectiveness.
A program42 titled Lookin’ Out was created in Pennsylvania by Erie Insurance to educate teens and promote awareness of driving safety issues. This program recruited teens to lead safe driving campaigns targeted at their peers. These campaigns included televised public service announcements created by teens to promote safety belt use. There was no evidence of the program’s effectiveness provided in the document.
Several brief summaries (Traffic Safety Digests) provided by NHTSA give shortened descriptions of teen safety belt programs, but many of these do not provide evidence in support of the programs [The database for Traffic Safety Digests can be searched by date at www.nhtsa.dot.gov/people/outreach/safetydige/].
Another brief NHTSA report236 described a program titled Ground Zero. This educational program used high-energy multimedia presentations at 18 Idaho high schools to promote safety belt use and to reduce impaired driving. Again, no evidence was provided regarding the effectiveness of the program.
Delaware’s TEARS (Troopers Educating About Roadway Safety) project was also described.234 This was a teen educational program to increase awareness of the dangers of impaired driving, speeding, and not wearing a safety belt. Within this program State police gave presentations at high schools about recent fatal accidents involving teens in the area. The description of the program said that it “has not been formally evaluated,” thus no evidence of its effectiveness was included.
Several other programs were described in the NHTSA’s Traffic Safety Digests, all of which were intended to promote teen safety belt use, but none were accompanied by any evidence. These programs included:
Further evaluations of the programs could be valuable in assessing their effectiveness in promoting teen safety belt use.
The 32 documents within this category described programs that were intended to address teen health behaviors other than safety belt use. Some of these strategies could be applied to the problem of teen safety belt nonuse. Some of the documents provided evidence of program effectiveness, while others would require further examination to determine their value. The most relevant programs in this category addressed teen safe driving, although they did not specifically target safety belt use.
GDL laws can have safety belt use provisions, but most research on GDL laws that was reviewed for this project did not present evidence for safety belt use. However, GDL laws have been shown to have an impact on other teen safe driving behaviors. As previously mentioned, Ferguson48 reviewed literature on GDL programs and suggested they could increase safety belt use, but did not provide evidence. Other authors have investigated GDL effects on other behaviors. Molnar118 provided empirical evidence of positive GDL law effects on overall crash rates, evening crashes, night crashes, single-vehicle crashes, multi-vehicle crashes, and several other types of crashes. Along with Molnar and Shope’s empirical evaluation of GDL laws (in Michigan),145 these authors also conducted a literature review that strongly suggested GDL laws’ effectiveness in reducing crash rates.144 This review determined that every State with a GDL program showed reduced teen crash rates. Another document that was reviewed was a news article that cited the aforementioned Michigan study and provided a quick summary of some of its results.98
Research presented by the Insurance Institute for Highway Safety87 89 has shown GDL laws to be effective in reducing crash rates in Nova Scotia as well. Some review articles and secondary sources examined for this review cited studies that have evidence of GDL laws’ effects on driving safety.30 258 88 Williams182 also reviewed literature and, although he did not present statistical evidence, he suggested that GDL laws could reduce teen risky driving. GDL laws with safety belt provisions could be further evaluated in regard to their effects on teen safety belt use.
Research by Glendon and Cernecca65 showed that enforcement-based persuasive messages were effective in reducing teens’ self-reported behavioral intentions to speed (messages similar in format to street signs designed to reduce speeding by emphasizing the enforcement of safety belt laws). They found no difference in the effectiveness of attitude-based, behavior-based, or attitude-and-behavior based messages. They also found that anti-speeding messages were more effective than anti-drunk-driving messages.
Some documents in this category provided information about teen driving safety programs (not safety-belt-specific), but offered no evidence of their effectiveness. Although some of these programs may have had safety belt promotion components, these components were not mentioned in the documents reviewed.
Other documents described teen programs that were not targeted toward driving but toward other teen health issues. One document described strategies for promoting youth mental health and suggested that these are most effective when they are coordinated and systemic, and they enhance social-emotional competence.179 Many documents discussed programs for reducing teen substance abuse, including alcohol, tobacco products, and illicit drugs. Examples of these include:
Although not all of the programs mentioned within this category are directly relevant to teen safety belt use, insights could be drawn for future teen safety belt promotion strategies.
This category included documents describing general safety belt programs that could be applied to teens, but did not provide any evidence of effectiveness. A total of 26 documents fit in this category. Many of these documents were brief reports mentioning intervention programs, but not providing sufficient detail to evaluate the programs’ effectiveness. Although detailed descriptions of all of these programs would exceed the scope of this report, a brief mention of the programs can provide further indication of the breadth of efforts that have been expended to address safety belt problems in general.
Several documents described comprehensive safety belt promotion programs. These included:
Some documents within this category described safety belt laws such as primary enforcement,238 and a proposal to change the legal driving age from 16 to 17 in Georgia,52 but offered no evidence for the effectiveness of the laws.
Other documents described enforcement strategies. For example:
Many documents described educational strategies. However, none of these documents provide evidence of effectiveness. These included:
Several other types of interventions were described in documents within this category. These included incentive/reinforcement strategies such as:
A work site safety campaign, Do Buckle, Don’t Booze, was also described.254
Again, none of the documents within this category provided evidence of effectiveness, but further evaluation of these programs could determine their utility in addressing the problem of teen nonuse of safety belts.
An interesting category emerged during our review of literature. Some documents provided evidence that several safety belt strategies are not effective. Some of these documents raise challenges to previously cited studies. Further evaluation may be necessary to resolve these conflicts in evidence. Eleven documents fit this category.
The most controversial of these articles suggested safety belt laws have not effectively reduced crash rates. Richens, Imrie, and Copas136 reviewed literature and used evidence from previous studies in several countries to demonstrate that the passage of safety belt use laws has had no appreciable decrease in traffic fatalities beyond that achieved in countries without safety belt laws. These authors also claim safety belt laws in England have not reduced road deaths, and Sweden showed no benefit from safety belt laws as well. The findings are explained via a risk-compensation perspective, in which the authors suggest that drivers who wear safety belts feel safer and, thus, drive faster and more carelessly. Virtually every other State in the peer-reviewed literature shows safety belts to be effective in reducing injuries and fatalities in crashes.
A larger group of documents called into question the effectiveness of education strategies when used in isolation from other strategies. Some documents provided evidence or cited studies showing that traditional teen drivers’ education programs do not decrease crash rates,7 80 91 89 86 but rather they can lead to an increase in teen traffic crashes because they often have early licensure provision in which younger teens are getting behind the wheel.91 89 86 The Insurance Institute for Highway Safety91 further suggested that these drivers’ education programs are ineffective because they do not influence teens’ attitudes, which are a strong determinant of driving behavior. Some authors suggested that teen driver education programs should not be used alone; rather, they should only be incorporated into more comprehensive approaches.7
The Transportation Research Board of the National Academies166 suggested that the minimal safety belt reminder systems currently used in passenger vehicles, which are limited to eight seconds in duration, are ineffective. The authors suggest that a new system developed by Ford is preferable to the current industry standard (see category 2).
Other research has shown that a clinical intervention at pediatric medical practices incorporating an “office systems approach” was ineffective in promoting safety belt use.160 The intervention included clinicians’ messages that promoted family rule setting, and quarterly newsletters to reiterate the clinicians’ messages.
Other, somewhat relevant research suggested that some persuasive messages promoting driver safety can have an adverse impact with some teens (particularly males) in that they showed a reaction against the messages and increased their behavioral intentions for negative behavior. In a study investigating the effectiveness of different message types in reducing speeding and drink-driving intentions it was revealed that some anti-drink-driving messages actually increased intentions to drink-drive. This occurred for both males and females. Furthermore, there was a similar increase in intentions to speed following an anti-speeding message, but this only occurred for males. The authors suggested that this finding might be explained by reactance theory, although the theory does not account for the gender difference in the anti-speeding finding. They also suggested that the finding might have been due to some type of response bias in which the responses on the behavioral intentions questions may have been more of a reported opinion about the message's effectiveness rather than a true report of intentions to drink and drive. The authors, however, ultimately concluded that "some anti-drink-driving messages could have negative effects on drink-driving behavior for some drivers."65
Last, and not quite as relevant, Donaldson, Piccinin, Graham, and Hansen34 found that resistance skills training in substance abuse could have negative outcomes because it can increase teens’ estimations of their peers’ substance abuse, which can have an impact on their own substance abuse decisions. This is somewhat relevant to the safety belt issue in that it indirectly suggests that messages describing safety belt nonuse as a “popular” behavior could negatively influence teens to adopt such a behavior. Further research on these noneffective strategies could add new insights into the battle to promote teen safety belt use.
The remaining documents reviewed for this report did not fall within any of the aforementioned categories. Thus, they were lumped together as “unspecified” and were determined to be less important for the purpose of this review. However, some relevant information was contained within the documents, such as usage rate statistics, other teen traffic safety statistics, characteristics of teen drivers, demographic factors relevant to belt use, and other teen health issues. These documents had no mention of any safety belt intervention programs. Thus, they were not centrally important for this literature review section and their descriptions were omitted.