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Effectiveness: For programs supporting enforcement 4 Star For programs supporting enforcement Cost: Varies
Use: Unknown
Time: Medium

Nationally in 2018, daytime seat belt use was at 89.6%, with 47 States and the District of Columbia having seat belt use at 80% or higher (NCSA, 2020a). This indicates the large majority of drivers and passengers are wearing their seat belts during daytime hours; however, there remains a proportion of the population who still do not buckle up regularly.

Generally, seat belt use rates for male occupants are lower than rates for female occupants, 87.7% and 92.0% respectively in 2018 (Enriquez, 2019). This trend has been evident since at least 2005. Similarly, belt use rates for occupants 16 to 24 tend to be lower than the use rates of other age groups. In 2018 belt use was 91.3% for occupants 8 to 15, 87.6% for occupants 16 to 24, 89.5% for occupants 25 to 69, and 92.4% for those occupants 70 and older. Since 2005, belt use rates for Black occupants have been lower than use rates for members of other races. In 2018 belt use for Black occupants was 85.5% compared to 89.7% among White occupants, and 92.6% among members of other races. Additionally, NHTSA’s 2019 National Occupant Protection Use Survey reported belt use was lower for front seat passengers (89.8%) compared to drivers (90.9%), and pickup truck occupants (85.6%) compared to occupants of passenger cars (91.2%) and vans/SUVs (92.5%) (NCSA, 2019). NHTSA’s 2007 national Motor Vehicle Occupant Safety Survey (MVOSS) found the same patterns with males, young drivers, rural drivers, and pickup truck drivers-all reporting lower seat belt use (Boyle & Lampkin, 2008). An in-depth examination conducted in Louisiana of driver factors underlying self-reported seat belt use found that, in addition to demographic factors, driver motivations and habits were strong correlates of belt use (Schneider et al., 2017). Internal (want to) and external (have to) motivations to wear a seat belt along with having a well-formed habit of buckling early in a trip were associated with 100% belt use. Motivated drivers who were nevertheless inconsistent seat belt users typically lacked well-formed seat belt use habits and routines.

Most non-seat belt users report wearing seat belts at least some of the time. In NHTSA’s 2007 national MVOSS, only 1% of drivers said they never used their seat belts and another 1% said they rarely used seat belts (Boyle & Lampkin, 2008). Passenger seat belt use also appears to be strongly associated with driver belt use (Han, 2017). The most frequent reasons given by drivers for not wearing a belt were that they: were only driving a short distance (59%), forgot (52%), were in a rush (39%), or they found the belt uncomfortable (35%) (Boyle & Lampkin, 2008). Drivers were able to give more than one reason for not wearing a belt so the percentages do not add up to 100%.

Riding as a backseat passenger is another factor that affects seat belt use. In one survey, 72% said they always use their belt in the back seat, compared to 91% who said they always use their belt when seated in front (IIHS, 2017). A recent analysis of data from the 2016 MVOSS found that 63% of rear-seat passengers reported being full-time users, 26% reported being part-time users, and 11% reported being non-users (Spado et al., 2019). The factors that had the strongest association with rear belt use included support for rear-belt laws, using a belt in the front seat, and belief that their State has a rear-belt law.

Use: Communications and outreach campaigns directed at low-belt-use groups are common, but no summary is available.

Effectiveness: Communications and outreach campaigns directed at low-belt-use groups have been demonstrated to be effective for targeted programs that support, and are supported by, enforcement. The effectiveness of stand-alone programs not supported by enforcement is unclear, though North Dakota has demonstrated success with its 2003 “Pick Up the Habit for Someone You Love” campaign (North Dakota DOT, 2004).

Trauma Nurses Talk Tough, originally developed in Oregon in 1988, is a seat belt diversion program implemented by trauma nurses in a hospital setting that targets drivers who have been ticketed for not wearing a seat belt. The program was implemented in Robeson County, North Carolina, a diverse county whose seat belt rates were consistently lower than the rest of the State. Those who went through the program were more likely to have a positive outlook on the use of seat belts. Following the program, observed seat belt use increased significantly in the county at 8 survey locations (from 81% to 86%) and 2 additional sites (from 69% to 78%) (NHTSA, 2014b; Thomas et al., 2014).

Demonstration programs conducted in Kentucky, Mississippi, North Dakota, and Wyoming from 2004 to 2007 sought to increase seat belt use through a variety of innovative approaches. The primary method employed by Mississippi, North Dakota, and Wyoming was to target low- belt-use counties for additional enforcement and enforcement focused publicity. The seat belt laws in Kentucky and Mississippi were also upgraded from secondary to primary enforcement during the demonstration programs. All 4 States achieved significant statewide increases in belt use above baseline belt use rates (Blomberg et al., 2009).

A variety of low-belt use groups have been targeted by countermeasure efforts. These are discussed in separate sections below.

Young Males: High-visibility enforcement programs generally have been effective in increasing belt use (see the Seat Belts and Child Restraints chapter, Section 2.1; Shults et al., 2004). Their publicity messages and placement can be directed at specific lower-belt-use groups. The 2013 Click It or Ticket campaign targeted 18- to 34-year old males and found they showed greater increases in awareness of seat belt enforcement activity and seat belt checkpoints than the general population (14% versus 10% for seat belt enforcement and 10% versus 7% for seat belt checkpoints, respectively) (Nichols, Chaffe, Solomon, & Tison, 2016).The target group did not show significant increases in awareness of the CIOT slogan (5%), messages to buckle up (6%), or perceived risk of a ticket (6%), while the general population showed significant increases in these indices (6%, 8%, and 5%, respectively). The small sample size for the target group may have contributed to not finding significant increases among this group for some indices.

Pickup Truck Drivers: The 5 States of NHTSA’s Region 6 conducted a two-week Buckle Up in Your Truck paid advertising campaign immediately before their May 2004 Click It or Ticket campaign. The truck campaign’s message complemented the Click It or Ticket message by focusing on the dangers of riding unrestrained in a truck and stressing the usefulness of belts in rollover crashes. The campaign spent nearly $600,000 for paid advertising in the 5 participating States. Surveys at the end of the campaign, before any enforcement-based Click It or Ticket publicity, showed that belt use among pickup truck occupants increased by about 2 percentage points. Following the Click It or Ticket publicity, belt use among pickup truck occupants increased by another 6 percentage points (Solomon, Chaffe, et al., 2007).

In a November 2004 follow-up study, an intensive campaign using the same Buckle Up in Your Truck message was conducted in Amarillo, Texas. The campaign used paid advertising emphasizing belt law enforcement as well as earned media featuring local LEOs. Belt use in pickup trucks increased by 12 percentage points in Amarillo and belt use in cars increased by 8 percentage points. At the same time, belt use in a comparison community increased by 5 percentage points for pickup truck occupants and by 4 percentage points for car occupants (Solomon et al., 2007).

Iowa, Kansas, Missouri, and Nebraska (in NHTSA’s Region 7) implemented a similar Buckle Up in Your Truck program in May 2006 and 2007. The campaign sought to increase seat belt use among pickup truck occupants by focusing on the dangers of riding unbuckled and increasing awareness of ongoing enforcement efforts. Following this campaign, these States also conducted statewide Click It or Ticket campaigns that included additional paid media and enforcement directed at occupants of all vehicle types. The Buckle Up in Your Truck campaign did increase the awareness of “buckle up in trucks” messages, but in terms of observed seat belt use, the Click It or Ticket campaign had the greater effect (Nichols et al., 2009).

North Dakota’s Pick Up the Habit for Someone You Love campaign in 2003 provides one of the few examples of a successful communications and outreach program not directly connected to enforcement. It was directed at male pickup drivers, whose pre-program belt use was 20 percentage-points lower than the statewide 63% rate. A survey of these drivers identified effective message goals (choose and remember to buckle up), message strategies (motivation through loved ones, sometimes using humor), and message placement (combining paid and earned radio and television, posters, and public relations events) (North Dakota DOT, 2004). The program increased observed belt use of male pickup drivers by 7 percentage points at a total cost of $295,000.

The North Dakota and Amarillo campaigns are well-documented examples of successful programs that target low-belt-use groups. They used all the characteristics of effective communications and outreach campaigns: good target audience research, effective and creative message development, and good message placement using both paid and earned media. The overall South-Central Region campaign produced only modest gains, but Kentucky (67% to 76% statewide), Mississippi (58% to 65% in targeted counties), North Dakota (66% to 80% in targeted counties), and Wyoming (55% to 70% in targeted counties) were able to achieve significant increases in seat belt use through their programs (Blomberg et al., 2009).

Rural Drivers: NHTSA’s Region 5 implemented a Rural Demonstration Program (RDP) prior to the May 2005 Click It or Ticket mobilization. The goal of the RDP was to evaluate strategies for increasing seat belt usage in rural areas. Paid media was used to notify rural residents that seat belt laws were being enforced. Active enforcement was included during the initial phase in 3 of the six Region 5 States (Illinois, Indiana, Ohio), but only the paid media component was implemented in the remaining three States (Minnesota, Michigan, Wisconsin). During the Demonstration Project phase, States that had intensified enforcement had significant increases in usage in their targeted rural areas (Nichols et al., 2007). All six Region 5 States intensified enforcement during the Click It or Ticket mobilization, but States that had intensified enforcement during the Demonstration Project showed substantially greater overall statewide gains during the Click It or Ticket phase than did the States that had not intensified enforcement during the RDP.

More recent evaluations of rural programs following the HVE model have yielded mixed results. An evaluation of Rural Initiatives conducted in Missouri and Kansas showed positive outcomes (Thomas & Blomberg, 2016). These States ran multi-wave HVE campaigns focused on rural counties from Spring 2009 to Spring 2010. The evaluations reported that seat belt use in the rural Missouri counties increased from 66.4% to 69.2%, while seat belt use in the rural Kansas counties increased from 61% to 70%. However, not all counties covered by the program experienced significant increases. Driver awareness of the targeted seat belt safety messages also increased following local media campaigns. A multi-state RDP that covered rural parts of Florida, Georgia, and Tennessee was less successful (Nichols, Chaffe, Solomon, & Tison, 2016). It included an HVE model paired with paid and earned media in four waves from November 2008 to May 2010, and it overlapped with annual CIOT campaigns. The RPD increased driver awareness of rural seat belt messages and the perceived risk of getting a ticket for driving unrestrained. Seat belt use increased in all three States but was only significantly greater than at control locations in Georgia. Concurrent, statewide CIOT may have muted the differences relative to control, and the greater effectiveness in Georgia may have been partially attributable to the broader awareness among drivers of seat belt check points (Nichols, Chaffe, Solomon, & Tison, 2016).

Native American Drivers: A multifaceted program was implemented on the Pine Ridge Indian Reservation (PRIR) in South Dakota to address the reservation’s high proportion of fatal motor vehicle crashes and chronically low seat belt use rates (Amiotte et al., 2016). Although the PRIR was covered by an existing primary seat belt law adopted by the Oglala Sioux Tribe, the law was rarely enforced by PRIR tribal courts and LEOs stopped issuing seat belts tickets. This contributed to seat belt use rates that were as low as 10% across the PRIR. The program implemented by the PRIR included data collection on belt use, increased policing resources and enforcement, funding for a traffic court to enforce seat belt citations, funding for injury prevention specialists to address child restraint usage, and outreach  involving local media and school programs. These efforts resulted in a 34% increase in observed seat belt use on the PRIR between 2007 and 2013. Another study used similar multifaceted approaches for increasing child restraint use in five tribal communities (Billie et al., 2016). Separate programs were run in each community, and each included child restraint distribution and parent education, along with varying combinations of increased citations, checkpoints, and enhanced media campaigns. These efforts resulted in higher child restraint use rates in all five communities, with larger improvements occurring in communities with low initial use rates. An important factor in the success of these programs was tailoring the interventions to local communities and adapting programming and media messages in culturally appropriate ways.

Costs: As with enforcement-related communications and outreach, costs vary depending on program quality and delivery. Paid advertising can be expensive.

Time to implement: A good media campaign will require 4 to 6 months to plan and implement.