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LITERATURE REVIEW


Overview

A comprehensive review of literature and information resources was carried out to form the basis of an approach to discussing key issues and identifying potential solutions for safe driving. Because little information exists in these specific areas, a broad–based literature search was carried out for the following related topics:

• Family functioning and decision–making regarding relationships and care of older adults including support networks of the elderly; intergenerational relationships; and caregiving,

• Family members' and friends' awareness of medical conditions and functional impairments that impact driving safety,

• Substitute judgment; family and friends making decisions about medical procedures,

• Role of the health care community in assisting family and friends,

• Other public health concerns and issues of professional ethics,

• Social marketing campaigns, and

• Information resources targeted to older drivers and pedestrians and distributed by national, state and provincial government agencies, and not for profit organizations.

 

Objectives

Objectives of the literature and information resources review were to determine:

• Current knowledge about the feasibility of involving family and friends in assisting at–risk older drivers;

• Which groups of functionally impaired drivers need interventions; and

• What types of intentions family members can and should provide.

 

Methods

Key researchers and project consultants involved in areas related to the topics identified above were contacted to obtain relevant published and unpublished literature, information materials and data. With COTR assistance, the NHTSA librarian conducted a database search of relevant articles. A call for information resources was published in quarterly editions of the Transportation Research Board's Older Driver Committee Newsletter.

Draft reports were prepared including a review of the literature, an annotated bibliography, and content analysis of information resources, and were reviewed by the COTR, project consultants and other expert panelists. Reviewers provided or suggested additional literature and informational materials, which have been included in the final literature and information resources review report.

 

Summary of Findings

Identification of At–Risk Older Drivers

Most older adults continue to drive into very old age. While many older adults continue to drive safely, others develop declining functional abilities that negatively impact safe driving. Most older drivers compensate for functional changes on a voluntary basis by limiting their driving behavior to safer driving conditions. However, older drivers who are not aware of or refuse to admit to declining driving abilities are at–risk of involvement in crashes.

Family and friends may be in a good position to detect problems and intervene to assist the unsafe older driver to limit or stop driving. Family and friends often look to professionals for help and advice in these matters.

Older males are more at–risk than older females of unsafe driving. Older male drivers currently outnumber older female drivers even though older females outnumber older males about 2 to 1. Older males are also more likely than older women to be involved in fatal crashes.

Risk of crash involvement for older drivers is associated with number of miles driven, changing functional abilities, and the presence of certain medical conditions which impact vision, cognition, and physical functioning (Marottoli, 1993). It is estimated that about 10% of individuals have medical conditions that may lead to unsafe driving behaviors. Older drivers with cognitive and visual impairments may be most at–risk because many are not aware of or do not recognize their impairment.

These findings suggest that a subpopulation can be targeted for more focused and immediate intervention: males with particular medical conditions or functional impairments. Several information resources are available to family and friends to help them self–assess their older relative's risk of unsafe driving.

Currently, the best assessment for families to identify risk is available at driving assessment clinics that have established profiles on risk factor indices for at–risk drivers. There are no assessments to measure families' ability or willingness to intervene for safe driving. The Readiness for Change Model (Prochaska, Norcross, and DiClemente, 1994) may be adaptable for use to create a “Willingness to Intervene” measure.

Feasibility of Involving Family Members

Results of the 1990 AARP Intergenerational Linkages Survey (Bengston and Harootyan, 1994) demonstrate that ties exist across generations; adult children are generally able (have the opportunity) and are willing (through emotional ties and affection) to help older family members (parents, grandparents) maintain their well–being. Results also suggest that some adult children would also be generally able and willing to help older family members modify or stop unsafe driving. However, an unknown percent of problem drivers also have problematic relationships with family members or no family at all who would be willing and able to help (Noelker, 1996).

It is clear that contact with and attachment to parents is weaker for fathers than for mothers, even when parents remain married. Getting a child to intervene with the mother and her driving problems will be easier because of the nature of the mother/child relationship. Women are generally more compliant, more likely to respond to normative expectations, and less caught up with the norms associated with the automobile and independence. Older males are far more likely than older women to be married. Consequently, the wife must deal with the problem. We may ask how receptive elderly husbands are to their wives' advice to make major lifestyle changes, such as stopping drinking, smoking, or driving. Men who are problem drivers may need to be coerced more often than women into compliance. However, coercion must used with care; older males have the highest and fastest growing suicide rate (Noelker, 1996).

Consideration must be given to cohort effects and intergenerational linkages between future generations. While older male drivers currently outnumber older females, driving patterns among baby boomer women indicate increasing numbers of women will continue to drive at older ages. Boomer women are more inclined to engage in unhealthy behaviors shunned by older women (smoking, substance abuse, etc.). Women's death rates from lung cancer, heart disease, and other lifestyle conditions are increasing and approaching those of men. Perhaps the boomer generation will be more inclined to engage in unsafe driving. This suggests that interventions targeted to the elderly of today may not be appropriate for future cohorts (Noelker, 1996).

Caregiving

As older adults begin to drive more and more infrequently, family members, friends, and neighbors often provide transportation. Giving rides to older adults may serve as a marker of one's entry into the caregiver/care recipient roles. Whitlatch and Noelker (1996) found the characteristics influencing the likelihood that a family member will assume the caregiving role are classified as “predisposing” (race, age, gender), “enabling” (access to resources, education), and “need factors” (onset of illness, loss of functioning).

Primary caregivers (usually a spouse or adult daughter) are the direct providers of care, performing and overseeing activities and tasks (including driving) for the care recipient. Seventy–five percent of primary caregivers are close family members. Women are more likely than men to assume this role. Men, however, are more likely than females to provide assistance in decision–making and financial management. Secondary caregivers are unpaid individuals who provide supplemental assistance (Whitlatch & Noelker, 1996).

The ability of families to take action in the area of caregiving is related to their degree of control over their environment and ability to adjust to change. This range in ability follows 5 levels of functioning which from highest to lowest are: mastery, coping, striving, inertia, and panic (Sterns, Weis, and Perkins, 1984). Families who function at the mastery level would be best able to cope with the older drivers changing abilities and intervene to help, while those at the panic level would be least able to help.

Only 25% of caregivers are friends, extended kin, or neighbors. In the absence of family ties, women are more likely than men to have friends as caregivers. Friends and neighbors are an important source of help. Seventy percent of adults provide assistance to friends and neighbors in their communities (Bengston and Harootyan, 1994).

Interestingly, at least one research study reported that individuals who provide rides for functionally impaired elderly are the same people who also provide informal support activities for those elderly (Kington, Reuben, Rogowski, and Lilliard, 1994). The literature on intergenerational linkages and caregiving indicates family members generally help the older generation when help is needed. However, the types of family relationships and levels of family conflict indicate some families provide more help than others; some families can cope better with family responsibilities than others. For example, 48% of adult children report having a helping relationship with their elderly mothers while only 38% report having a helping relationship with their fathers (Bengston and Harootyan, 1994).

However, there is no clear indication of the percent of families who fall into different levels of conflict. Presumably, helping families have less conflict and better coping skills than non–helping families. One can surmise that more supportive families have disproportionately fewer problem drivers, while alienated, independent, and conflict–ridden families have more.

Readiness for Change

Prochaska, Norcross and DiClemente (1994) in Changing for Good discuss the process of changing problem behaviors for individuals who behave in undesirable ways. Research results reveal stages in the change process that those with problem behavior must undergo in order for change to occur. Before change can occur, the problem behavior must be recognized. Precontemplation is the stage prior to problem recognition. Thinking of problem driving, in this stage there is problem denial, resistance to modifying unsafe driving behaviors, or driving cessation. During the contemplation stage, the at–risk driver reevaluates the driving situation. During the action stage, “healthy responses are substituted for problem behaviors.” Problem driving is substituted by modifications for safer driving patterns or driving cessation. At–risk older drivers who have no family and friends to serve as caregivers may be less likely to change or modify their problem driving behavior. Such support would be important for older drivers who have reached the action stage, and need help to change or stop unsafe driving.

Unlike other problem behaviors, such as smoking or alcoholism, the maintenance stage does not generally pose a threat to older drivers for reversion to unwanted behaviors. The stages and processes in the model including problem denial, problem recognition, preparation for change, taking action to change, maintaining change, and ending the problem permanently are the same for stopping smoking, substance abuse, weight gain, or unsafe driving.

Recognition of Medical Conditions by Family and Friends

Many family members and friends are aware of older drivers' medical conditions through direct observation or hearing about the elders' problem driving situations. Many are also aware of unsafe driving practices. However, family members of older drivers with Alzheimer's disease may have difficulty recognizing poor driving ability. Other family members may be unaware of or not recognize either medical conditions or unsafe driving practices.

In the AARP study on intergenerational linkages (Silverstein, Lawton, & Bengston, 1994), about as many parents and adult children reported strong helping as reported independent relationships. And although most frail elderly have a family member or friend they can count on for help, one may not assume that all older drivers in independent families will in fact receive some level of help should they become unable to drive.

It is important to encourage family and friends to assist the problem older drivers. Perhaps more importantly, those less likely to involve themselves with a problem older driver must be motivated to help as well.

Interventions

The vast literature on caregiver interventions focuses primarily on treatment effectiveness outcomes. Treatments include group interventions, or psychotherapeutic approaches, such as support groups; educational approaches which emphasize learning new care–related or problem–solving skills; and family systems approaches that involve both the caregiver and care recipient in the development of a care plan (Zarit and Teri, 1990). Studies that review levels of success reveal no clear direction. Treatments are effective mainly among caregivers who are receptive to them (Brugois, Schulz, & Burgio, 1996).

The meager literature on family and friends in assisting unsafe older drivers focuses on one of 3 major steps in the sequence of intervening. The first step in intervening uses the family member's direct observation as a passenger to identify how well the older adult drives (Malfetti and Winter, 1991). This set of interventions relies on the family member's observation skills. The family member will decide whether intervention is even necessary and if so, begin plans to take action. The family members observations should include noting the extent to which the older driver:

• Copes with traveling along familiar routes

• Sees out of the car

• Operates the controls

• Observes the rules of the road

The second step in intervening may consist of specific suggestions to the older driver to take remedial action to measure or improve driving skills. Interventions consist of the following (Malfetti and Winter, 1991):

• A self–assessment test for driving performance. The test should be user friendly; fun or entertaining; safe, valid and reliable; endorsed by national agencies, for example, NHTSA, AAA, AARP, etc. (Nielsen, 1996)

• A driver improvement course

• An eye exam

• A medical exam and physical fitness test

• Review of OTC and prescription drugs the older driver may be taking

• A test for a graded license using valid and reliable assessment tools

The final step in intervening specifies actions family and friends can take to stop the older driver from driving (Hunt, 1994). These include:

• Exchanging the car keys with a set of useable keys

• Disabling the car by disconnecting the distributor cap or car battery

• Removing the car by selling it, or parking it around the corner

• Providing rides, or chauffeuring, the impaired older driver

• Meeting mobility needs by arranging for alternative transportation instead of the unsafe older driver driving himself or herself

• And, as a last resort, reporting the problem older driver to state authorities in states that permit such reporting

Healthcare professionals influence the older driver in driving decision–making, and should play an important role in assessing driving abilities. However, mandatory physician reporting exists in few states. Family members may expect more help from healthcare professionals than many are able or willing to provide (Reuben & St. George, 1996).

A number of cultural, social, and psychological barriers may prevent family members from intervening. Ethical considerations for intervention or keeping a potentially unsafe older adult from driving are articulated by professionals who attempt to balance public safety and personal freedom.

There is no quantitative data to indicate the proportion of family members who tried the specific interventions indicated above or the outcomes. A longitudinal study following older drivers and potential caregivers is indicated to learn more about interventions used and their success rate.

Content Analysis

Information materials about driver safety were reviewed. A content analysis was carried out to determine the types of organizations that tend to publish such materials; the degree to which the materials target family and friends versus other concerned groups; types of formats used; and topics of information commonly discussed. A total of 79 public information items generally available to the public at–large were collected and reviewed.

The most common distribution source for older driver safety materials is state and provincial transportation or related departments, accounting for 40% of all reviewed publications. Close to half (46%) of all materials collected are brochures. Especially common are 6 panel and 4 panel brochures. AARP offers the largest selection of publications (11) followed by the American Automobile Association (7) and the AAA Foundation for Traffic Safety (5). Over 65% of publications are targeted to older drivers. Only 15% are designed specifically for caregivers, including family members. Two publications target professionals.

The publications cover a wide array of topics in 14 content areas: older driver safety; vehicle design and adaptation measures; vehicle maintenance; environmental/road design and adaptations to roadway conditions, weather, and signs and signals; driver improvement and rehabilitation; behavior change; occupant protection; aging and health; professional referral sources; licensing issues and procedures; transportation options; driving cessation; assessment tips; and counseling tips. However, almost half of the publications address only 5 or fewer topics. Only one addresses all 14 topics. Less than half mention the possibility of driving cessation and less than one–third specifically advise or make reference to using alternative transportation.

Most materials deal with the issue of driver safety on a very general level and suggest direct and simple remedial or compensatory actions to help prolong safe driving. The scope and quality of advice and tips in the materials vary. Few materials target different problem subgroups or deal with specific medical or functional impairments. Information is limited on specific interventions to use with high–risk drivers unwilling or unable to self–regulate. The topic of reporting unsafe drivers to state authorities is also rarely addressed. Future outreach efforts should address these voids so that older drivers, and the general public can be better informed. Family and friends need to be prepared to anticipate and respond to necessary driving limitations and cessation.

Social Marketing

In their statement of work, NHTSA emphasized the need to identify personal and social barriers standing the way of involvement in an older relative’s or friend’s driving decisions. NHTSA has also called for formative research, including focus group interviews, to provide the basis for framing interventions, messages, and incentives that can overcome these barriers. Such research is a cornerstone of social marketing programs, which focus on designing health– and safety–oriented appeals to change behavior. At least one recent publication links social marketing and traffic safety (OECD, 1993).

Figure 1 illustrates a social marketing framework for road safety. The framework recommends conducting a market analysis based on results of consumer and cost/benefit research; developing a market strategy or approach; implementing marketing strategies and tactics to solve social problems addressed by the marketing campaign; evaluating the results of the initial campaign; making improvements in campaign features; and finally, disseminating the study results.

Social marketing techniques may be applied to the development of guidelines and public information materials for improving driver safety. Themes and messages would address the behaviors of at–risk older drivers, their families and friends, professionals and other authorities, as well as the broader social and policy contexts that are shaping influences on these behaviors.

 


FIGURE 1:

A SOCIAL MARKETING FRAMEWORK FOR ROAD SAFETY


Market analysis

• Review and, if necessary, carry out consumer studies ensuring adequate market segmentation into homogeneous key target groups to improve understanding of consumers' perception of “problems” and potential solutions.

• Assess costs and benefits associated with alternative remedial strategies.

Formulate marketing strategy

• Select problems and groups to be targeted.

• Select remedial measures including communication strategy(ies) to be applied.

• Identify potential barriers and possible solutions.

• Set objectives which are realistic, achievable, and measurable. The following topics should be considered: collisions, behavior, attitudes, knowledge. All objectives should be consumer oriented.

• Decide marketing instruments and marketing mix to maximize cost benefits to consumer through “voluntary mutual exchange”:

• product
• price
• place
• promotion

• Produce communication brief to maximize impact on target audience specifying:

• budget
• media strategy
• messages
• target audiences
• styles/themes of communications

• Pretest proposals on target consumers for acceptability, comprehension, credibility, capability and motivation to implement.

• Adapt and re–test proposals as necessary.

• Decide process and summative evaluation measures.

Implement remedial measures, marketing instruments and evaluation program.

Obtain feedback from findings and adapt remedial program, when possible

Publish and disseminate study results


Source: Organization for Economic Cooperation and Development (OECD), 1993.

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