The effectiveness of mass media campaigns in increasing the use of seat belts: A systematic review

Education, incentive, and engineering-based interventions to promote the use of seat belts

BACKGROUND

Over 1.3 million people die each year as a result of traffic collisions and hundreds of thousands of others are permanently and seriously injured. Most of these deaths occur in low- and middle-income countries, where mortality rates can be up to 10 times higher than those of some high-income countries. Seat belts are designed to accomplish two key functions - to prevent the occupant from being ejected from the vehicle by the force of impact, and to extend the time that the decelerating force is applied to a person. Seat belts also spread the area of impact both to larger and less vulnerable parts of the body. Since the 1950s, seat belts have been factory-fitted to most vehicles, and today around 90% of high-income countries have adopted seat belt legislation that makes it mandatory for some, if not all, vehicle occupants to wear seat belts. However, the simple passing of laws is not sufficient to ensure seat belt use, and, while the enforcement of seat belt laws does increase seat belt use, other interventions have been developed to encourage voluntary - and hence sustainable - behaviour change.

OBJECTIVES

To evaluate the benefits of behavioural-change interventions (educational-based, incentive-based, engineering-based, or a combination, but not enforcement-based) that promote the use of seat belts, and to determine which types of interventions are most effective.

SEARCH METHODS

On 9 August 2022, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), OvidSP Embase, OvidSP MEDLINE, 14 other databases, and clinical trials registers. We also screened reference lists and conference proceedings, searched websites of relevant organisations, and contacted road safety experts. The search was performed with no restrictions in terms of language and date of publication.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), both individually randomised and cluster-randomised, that evaluated education, engineering, incentive-based interventions (or combinations) that promoted seat belt use.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the eligibility of RCTs, evaluated the risk of bias, and extracted data. We performed a narrative synthesis based on effect direction due to the heterogeneity observed between RCTs and reported the synthesis in accordance with reporting guidelines for systematic reviews without meta-analysis, as appropriate. We assessed the certainty of the evidence using the GRADE approach. We analysed data on the primary outcome, frequency of wearing a seat belt. None of the included RCTs reported the other primary outcome, crash-related injury rate or the secondary outcome, crash-related mortality rates of interest in this review.

MAIN RESULTS

We included 15 completed RCTs (12 individual, parallel-group, and three cluster) that enroled 12,081 participants, published between 1990 and 2022. Four trials were published between 2019 and 2022, and the remaining trials were published 10 or more years ago. We also identified four ongoing RCTs. Thirteen RCTs were conducted in the USA. Trials recruited participants from various sites (worksites, schools, emergency departments, a residential retirement community, and primary care settings) and different age groups (adults, late adolescents, early adolescents, and dyads). Thirteen trials investigated educational interventions, one of which used education in addition to incentives (one of the intervention arms) measured through participant self-reports (12) and observation (one), and two trials investigated engineering-based interventions measured through in-vehicle data monitor systems at various follow-up periods (six weeks to 36 months). We grouped RCTs according to types of education-based interventions: behavioural education-based, health risk appraisal (HRA), and other education-based interventions. The evidence suggests that behavioural education-based (four trials) interventions may promote seat belt use and HRA interventions (one trial) likely promote seat belt use in the short term (six weeks to nine months). Four of the six trials that investigated behavioural education-based interventions found that the intervention compared to no or another intervention may promote seat belt use. These effects were measured through participant self-report and at various time points (six-week to 12-month follow-up) (low-certainty evidence). One of the three trials investigating HRA only or with additional intervention versus no or another intervention showed observed effects likely to promote seat belt use (moderate-certainty evidence). The evidence suggests that engineering-based interventions using vehicle monitoring systems (with in-vehicle alerts and with or without notifications/feedback) may promote the use of seat belts. One trial showed that engineering interventions (in-vehicle alerts and feedback) may promote seat belt use while the other showed unclear effects in two of the three intervention groups (low-certainty evidence). Both trials had small sample sizes and high baseline seat belt use.

AUTHORS' CONCLUSIONS

The evidence suggests that behavioural education-based interventions may promote seat belt use and HRA (including incentives) with or without additional interventions likely promote seat belt use. Likewise, for engineering-based interventions using in-vehicle data monitor systems with in-vehicle alerts, with or without notifications/feedback the evidence suggests the interventions may promote the use of seat belts. Well-designed RCTs are needed to further investigate the effectiveness of education and engineering-based interventions. High-quality trials that examine the potential benefits of incentives to promote seat belt use, either alone or in combination with other interventions, as well as trials to investigate other types of interventions (such as technology, media/publicity, enforcement, insurance schemes, employer programmes, etc.) to promote the use of seat belts, are needed. Evidence from low- and middle-income economies is required to improve the generalisability of the data. In addition, research focused on determining which interventions or types of interventions are most effective in different population groups is needed.

The Impact of Protective Devices Across the Spectrum of Trauma Care and Across Racial Groupings

INTRODUCTION

Protective devices such as seat belts and helmets save lives. Most studies only address one aspect of the injury profile - compliance or mortality - not the entire spectrum of trauma care, and little attention is paid to racial differences in the use or impact of protective devices.

METHODS

Patients with blunt mechanisms where using protective devices would be expected were included and were divided into utilizing (P) vs not utilizing protection (Non-P). Chart review included demographics, injuries sustained, hemodynamics, and blood alcohol level. Outcomes included need for emergent operation, complications and death.

RESULTS

Non-P patients were more likely male, presented at night and intoxicated. Highest risk behavior (intoxicated Non-P) presented at night (25.7% of nighttime presentations), and rarely during daytime (6.7% daytime presentations). Non-P were more likely hypotensive and sustain a traumatic brain injury. No race related differences were noted among young patients. Among older (>/=50 years) patients, White patients were least likely Non-P and least likely presented at night. Non-P required more emergent operative intervention, ICU admission, and longer hospital stay. Overall, Non-P was associated with increased risk of death (OR = 1.6 (95% CI = 1.28 - 2.11).

CONCLUSION

Given unique age and racial differences, we advocate for culturally and age specific public service campaigns.

Preventable tragedies: findings from the #NotAnAccident index of unintentional shootings by children

BACKGROUND

Between 2015 and 2021, 3,498 Americans died from unintentional gun injuries, including 713 children 17 years and younger. Roughly 30 million American children live in homes with firearms, many of which are loaded and unlocked. This study assesses the scope of unintentional shootings by children 17 and younger in the US and the relationship between these shootings and state-level secure storage laws.

METHODS

Demographic and injury data of both perpetrators and victims of unintentional shootings by children 17 and younger in the US from 1/1/2015-12/31/2021 were extracted from the #NotAnAccident Index. The #NotAnAccident Index contains media-report data, which is systematically flagged through Google Alerts. We describe characteristics of incidents and examine incident rates over time. The association between state-level secure storage laws and rates of unintentional shootings by children is assessed in multivariate negative binomial regression models.

RESULTS

2,448 unintentional shootings by children resulted in 926 deaths and 1,603 nonfatal gun injuries over a period of seven years. Most perpetrators (81%) and victims (76%) were male. The mean age was 10.0 (SD 5.5) for shooters and 10.9 (SD 8.1) for victims. Children were as likely to shoot themselves (49%) as they were to shoot others (47%). The majority of victims were under 18 years old (91%). Shootings most often occurred in or around homes (71%) and with handguns (53%). From March to December 2020, coinciding with the COVID-19 pandemic, incidents increased 24% over the same period in 2019, which was driven largely by an increase among shooters ages 0-5. Depending on the type of law, rates of unintentional shootings by children were 24% to 72% lower in states with secure storage laws, compared to states without such laws.

CONCLUSIONS

Unintentional shootings by children are on the rise, particularly among children 0-5 years old, but are preventable tragedies. Our results show that secure firearm storage policies are strongly correlated with lower rates of unintentional shootings by children. Firearm storage policies, practices, and education efforts are needed to ensure guns are kept secured and inaccessible to children.

The use of car safety seats for children in China: A questionnaire survey based on the theory of planned behavior

OBJECTIVE

The purpose of this study was to analyze the psychological characteristics underlying Chinese parents' behaviors in using child car seats and to understand their decision-making processes. Based on the theory of planned behavior (TPB), three extended variables of perceived accident severity, perceived benefits, and perceived barriers were introduced. From the perspective of social psychology, the psychological factors that influence parents' use of child car seats and their interrelationships were explored.

METHODS

A questionnaire was designed to collect data, including information on demographic characteristics, basic components of the TPB, and relevant extension variables. Using on online survey, 585 valid questionnaires were collected. Structural equation modeling was used to calibrate the data, and multiple group analysis was performed on the demographic variables.

RESULTS

The extended TPB can effectively explain and predict parents' behaviors when using children's car seats. The results of the model show that parents' positive attitudes toward child safety seats (CSSs), others' recognition of their own use and perceptual control of the use of CSSs increase their willingness to use CSSs. Parents' willingness to use has a positive impact on the use of CSSs. Additionally, for the three extended variables introduced, perceived benefit significantly promoted parental intention and behavior to use CSS for children; perceived barriers significantly reduced parental use of CSS; and perceived accident severity had no significant effect on parental use of CSS.

CONCLUSIONS

This study established the validity of the extended TPB model in predicting parents' behaviors in using car seats for their children. In addition, the current findings may provide a theoretical basis for policy development to promote CSS use.

Designing illustrative social media stories to promote adolescent peer support and healthy sexual behaviors

Objective

Adolescent females in the United States continue to have unmet sexual and reproductive healthcare needs. Research shows that interventions incorporating peer support can augment perceived self-efficacy and reinforce healthy behaviors. Yet, few user-centered digital sexual health interventions incorporate peer support, and aim to change perceptions of peer norms and model social skills. The objective of this study was to design and demonstrate the receptivity of adolescent females to illustrated digital social media stories that promote healthy sexual behaviors and peer social support.

Methods

We conducted a three-phase study approved by our Institutional Review Board. In Phase 1, we presented sexually active adolescent female emergency department patients aged 14-19 with eight sexual health scenarios via a survey study. Participants wrote three text messages addressed to the protagonist of each scenario which motivated and encouraged her to consider the use of contraceptives. Messages were scored based on the construct of peer support (emotional, tangible, informational, and belonging). In Phase 2, we worked with a professional artist and screenwriter to design digital sexual health comics using the gathered messages. In Phase 3, we gathered feedback on the comics from adolescent female emergency department patients.

Results

Females (n  =  22) provided 352 messages. Using top rated messages, we designed five digital visualizations in a running story called Mari tells it like it is. Each story incorporated 5-12 peer-authored quotes. We inserted the final images into Instagram®. Additional females (n  =  39) found the images "relatable," "super-realistic," and "educational."

Conclusion

Collecting peer-authored texts from our local adolescent community led to the creation of well-received sexual health visualizations. This novel method of design incorporated adolescent voices to promote peer support and healthy behaviors.