seat belts & child restraints

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Seat-belts andchild restraintsA R O A D S A F E T Y M A N U A L

F O R D E C I S I O N - M A K E R S

A N D P R A C T I T I O N E R S



eat-belts and child restraints: a road sa ety manual or decision-makers and practitioners

ISBN - - - -

uggested citation:

Seat-belts and child restraints: a road sa ety manual or decision-makers and practitionersLondon, F A Foundation or the Automobile and ociety,

© FIA Foundation or the Automobile and Society.

Publications o the F A Foundation or the Automobile and ociety (F A Foundation) can beobtained rom www. a oundation.org

Permission to reproduce or translate F A Foundation publications – whether or sale or or non- commercial distribution – should be addressed to:F A Foundation60 ra algar quareLondon WC2 5DUnited KingdomEmail: mail@ a oundation.org

Te designations employed and the presentation o the material in this publication do not imply theexpression o any opinion whatsoever on the part o the F A Foundation or the Automobile and

ociety (F A Foundation), the World Health Organization (WHO), the Global Road a ety Partner-ship (GR P) and the World ank concerning the legal status o any country, territory, city or area oro its authorities, or concerning the delimitation o its rontiers or boundaries. Dotted lines on mapsrepresent approximate border lines or which there may not yet be ull agreement.

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All reasonable precautions have been taken by the F A Foundation, the WHO, the GR P and the World ank and the authors to veri y the in ormation contained in this publication. However, the published material is being distributed without warranty o any kind, either express or implied. Teresponsibility or the interpretation and use o the material lies with the reader. n no event shall theF A Foundation, the WHO, the GR P and the World ank or the authors be liable or damages aris-ing rom its use.

Editing and inside design by nís Communication: www.inis.ie



Table of contentsSeat-belts and child restraints: a road safety manual

T a b l e o

f c o n t e n t s

iii

Table o contents

Pre ace ix

Contributors and acknowledgements xi

Executive summary xiii

Introduction xv

Background to the series o manuals xvii

Background to the seat-belt and child restraint manual xixWhy was the seat-belt and child restraint manual developed? xixWho is the manual or? xixWhat does this manual cover and how should it be used? xxHow was the manual developed? xxiiDissemination o the manual xxiiiHow to get more copies xxiii

Re erence xxiv

The need or seat-belts a1. nd child restraints 1

1 1 Road tra c death and injury as a worldwide public health problem 31 1 1 Worldwide trends in road tra c death and injury 31 1 2 Types o injuries sustained by vehicle occupants 5

1 2 How seat-belts and child restraints prevent or minimize injury 61 2 1 What happens in a crash? 61 2 2 How a seat-belt works 71 2 3 How a child restraint works 7

1 3 Recommended types o seat-belts and child restraints 81 3 1 Seat-belt design 81 3 2 Types o child restraints 9

1 4 E ectiveness o seat-belt and child restraint use in preventing death andreducing injury 12

1 4 1 E ectiveness o seat-belts 12



Table of contents

iv

1 4 2 E ectiveness o child restraints 151 4 3 Seat-belt wearing rates 161 4 4 Child restraint use rates 19

1 5 E ectiveness o seat-belt and child restraint programmes at increasingwearing rates by vehicle occupants 19

Summary 22

Re erences 23

How to assess the situation i2. n a particular countr 25

2 1 The need to assess the current situation 272 1 1 Understanding the current situation through baseline data collection 272 1 2 Quality o the data 29

2 2 How to assess the extent o the problem o non-use o seat-belts andchild restraints 292 2 1 Assessing the extent o the vehicle occupant injury problem 302 2 2 What are the seat-belt and child restraint wearing rates in the area

being considered? 352 2 3 Why do people not wear seat-belts and use child restraints? 40

2 3 How to assess what is already in place 462 3 1 Who is in charge o road sa ety, and what unds are there or it? 462 3 2 Who are the stakeholders? 482 3 3 Is there a seat-belt use law in place? 492 3 4 Is there a seat-belt and child restraint standard in place? 512 3 5 Have any seat-belt and child restraint programmes been attempted

so ar? 512 3 6 Using the situational assessment to prioritize actions 53

Summary 53

Re erences 54

How to plan and manage3. a seat-belt programme 55

3 1 How to establish a working group 573 1 1 Who to involve? 583 1 2 Assigning roles to working group members 59

3 2 How to prepare and promote an action plan 613 2 1 Setting the programme’s objectives 61



Seat-belts and child restraints: a road safety manual

T a b l e o

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3 2 2 Setting targets 623 2 3 Choosing per ormance indicators 633 2 4 Deciding on activities 643 2 5 Setting a time rame and phasing the programme 643 2 6 Estimating resource needs 693 2 7 Setting up a monitoring mechanism 723 2 8 Ensuring sustainability o the programme 73

Summary 74

Re erences 75

How to develop and implement interventions4. 77

4 1 Increasing usage: the combined approach 81

4 2 Legislation and penalties 824 2 1 Developing seat-belt tting and usage laws 834 2 2 Identi ying legal responsibilities 864 2 3 Exemptions 864 2 4 Penalties or non-compliance 874 2 5 Developing and implementing legislation 894 2 6 Phasing implementation 914 2 7 Section summary: checklist or seat-belt legislation 92

4 3 Seat-belt standards and equipment 934 3 1 Adopting a standard or regulation 944 3 2 Types o standards or regulations and their content 974 3 3 Testing and certi cation 984 3 4 Vehicle inspection and seat-belt maintenance 994 3 5 Retrospective tting 1004 3 6 In-vehicle reminder systems 1024 3 7 Section summary: checklist or developing seat-belt standard

or regulation 103

4 4 Increasing usage: en orcement 1044 4 1 Pre-requirements 1044 4 2 En orcement strategy 1054 4 3 En orcement methods 1084 4 4 Police training 1094 4 5 Processing penalties 1094 4 6 Overcoming obstacles to en orcement 1104 4 7 Section summary: increasing seat-belt usage through en orcement 111



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vi

4 5 Increasing usage: voluntary measures 112

4 6 Increasing usage: publicity campaigns 1134 6 1 Objectives o the campaign 1154 6 2 Creating campaign messages 1164 6 3 Reaching the target audience 1184 6 4 Creative concepts 1194 6 5 Selecting an agency or the campaign 1224 6 6 Working with the media 1244 6 7 Campaign stages in relation to seat-belt legislation 1244 6 8 Evaluating the campaign 126

4 7 Increasing usage: other voluntary measures 1274 7 1 Employer regulation and incentive schemes 1274 7 2 Education and training 1294 7 3 Insurance and public incentive schemes 132

4 8 How to ensure an appropriate post-crash response 1334 8 1 Seat-belts and injuries 1354 8 2 Seat-belt removal 135

Summary 138

Re erences 140

How to evaluate t5. he programme 143

5 1 Planning the evaluation 1455 1 1 Aims o evaluation 1465 1 2 Types o evaluation 147

5 2 Choosing the evaluation methods 1515 2 1 Study types or ormative and process evaluations 151

5 2 2 Study types or impact and outcome evaluations 1515 2 3 Choosing the per ormance indicators 1565 2 4 Conducting an economic evaluation o a programme 1575 2 5 Determining sample size 158

5 3 Dissemination and eedback 1595 3 1 Checklist or evaluation process 1595 3 2 Using evaluation results to eed back into new planning cycle 159

Summary 160

Re erences 160




T a b l e o

f c o n t e n t s

vii

Appendices 163

Appendix 1 United Nations Economic Commission or Europe (UNECE)seat-belt questionnaire 165

Appendix 2 Sample seat-belt wearing observation orm 174

Appendix 3 Example seat-belt wearing law 175

Appendix 4 Inspecting seat-belts and their components ( romUnited Kingdom Vehicle Inspectorate inspection manual) 177

Appendix 5 Roadblock or checkpoint management 185

Appendix 6 Sample lesson plan or teaching seat-belt sa ety insecondary school 189

Partner organizations in the development o the manual 193

Glossary o terms 196

Re erences 20 0



PrefaceSeat-belts and child restraints: a road safety manual

P r e

f a c e

ix

Pre ace

Road tra c injuries are a major public health problem and a leading cause o death and injury around the world. Each year nearly . million people die andmillions more are injured or disabled as a result o road crashes, mostly in low- andmiddle-income countries. As well as creating enormous social costs or individuals,

amilies and communities, road tra c injuries place a heavy burden on healthservices and economies. Te cost to countries, many o which already struggle witheconomic development, may be as much as – % o their gross national product. Asmotorization increases, preventing road tra c crashes and the injuries they in ict will become an increasing social and economic challenge, particularly in developing countries. present trends continue, road tra c injuries will increase dramatically inmost parts o the world over the next two decades, with the greatest impact alling onthe most vulnerable citizens.

Appropriate and targeted action is urgently needed. TeWorld report on road tra c injury prevention, launched jointly in by the World Health Organization andthe World ank, identi ed improvements in road sa ety management and speci cactions that have led to dramatic decreases in road tra c deaths and injuries inindustrialized countries active in road sa ety. Te use o seat-belts, helmets and childrestraints, the report showed, has saved thousands o lives. Te introduction o speed

limits, the creation o sa er in rastructure, the en orcement o limits on blood alcoholconcentration while driving, and improvements in vehicle sa ety are all interventionsthat have been tested and repeatedly shown to be e ective.

Te international community must now take the lead to encourage good practicein road sa ety management and the implementation o the interventions identi edin the previous paragraph in other countries, in ways that are culturally appropriate.

o speed up such e orts, the United ations General Assembly passed a resolutionon April urging that greater attention and resources be directed towardsthe global road sa ety crisis. Resolution / on “ mproving global road sa ety”stressed the importance o international collaboration in the eld o road sa ety.A urther resolution (A/ /L. ), passed in October , rea rmed the United

ations’ commitment to this issue, encouraging Member tates to implementthe recommendations o theWorld report on road tra c injury preventionandcommending collaborative road sa ety initiatives so ar undertaken towardsimplementing resolution / . n particular, it encouraged Member tates to ocuson addressing key risk actors and to establish lead agencies or road sa ety. n ,the United ations passed a urther resolution calling or a ministerial con erence onglobal road sa ety.

o contribute to the implementation o these resolutions, the World HealthOrganization, the Global Road a ety Partnership, the F A Foundation or theAutomobile and ociety, and the World ank have collaborated to produce a series



Preface

x

o manuals aimed at policy-makers and practitioners. Tis manual on seat-belts andchild restraints is one o them. Each provides step-by-step guidance to countries wishing to improve road sa ety organization and to implement the speci c roadsa ety interventions outlined in theWorld report on road tra c injury prevention.Tey propose simple, cost-e ective solutions that can save many lives and reduce theshocking burden o road tra c crashes around the world. We encourage all to usethese manuals.

E K DirectorDepartment o njuries and Violence Prevention World Health Organization A w P cChie ExecutiveGlobal Road a ety Partnership

D v WDirector GeneralF A Foundation or the Automobile and ociety

A y BLead Road a ety pecialist

ransport and Urban Development Department World ank




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Contributors and acknowledgements

Advisory CommitteeAnthony liss, Etienne Krug, Andrew Pearce, David Ward

Editorial CommitteeKate McMahon, Andrew Downing, Kathleen Elsig, Andrew Pearce, Margie Peden,

ami oroyan, Rita Cuypers

Contributors to modules and boxes

ransport Research Laboratory, Kate McMahon, Cameron lack, Hung Dang Viet, ella Dinh-Zarr, Yvette Holder, Rebecca vers, tephen Jan, Charles Mock,David A leet



xii



Executive summarSeat-belts and child restraints: a road safety manual

E x e c u t i v e s u m m a r y

xiii

Executive summary

ncreasing motorization worldwide has brought increases in crashes and injuries to vehicle occupants, particularly in low- and middle-income countries. One o themost e ective measures to protect occupants rom injury in the event o a crash is the

tment and use o seat-belts and child restraints. Tey are proven to save lives andreduce injury severity, and all vehicle occupants should be appropriately restrained when travelling in a motor vehicle. eat-belts and child restraints are a secondarysa ety measure; though e ective, they do not reduce crash risk, or which other primary sa ety measures are needed, particularly to protect vulnerable road users.

Worldwide, however, not all vehicles are tted with seat-belts, and not all occupantsuse them when they are available. n countries where car use is rising most rapidly,the use o seat-belts and child restraints is low. More needs to be done to convince political leaders, police authorities, individual drivers and passengers that seat-belts provide essential protection rom injury and can reduce the consequences o a crash.Comprehensive programmes o legislation, law en orcement, public education and publicity are needed to promote the bene ts o seat-belt and child restraint use andto ensure compliance once legislation is in place.

Te purpose o this manual is to provide advice and examples that will lead toincreased use o seat-belts and child restraints as sa ety devices at a national level.Te manual is aimed at policy-makers and road sa ety practitioners and draws onexperience rom countries that have succeeded in achieving and sustaining highlevels o restraint use. t includes recommendations or developing and implementing technical standards and legislation, advice on how to monitor and evaluate progress,and suggestions regarding other multidisciplinary measures. A particular ocus is thedesign and implementation o a programme to increase seat-belt wearing and childrestraint use through legislation, en orcement and public education measures.

n developing the material or this manual, the writers have drawn on case studiesrom around the world to illustrate examples o “good practice”. Although speci cally

aimed at those countries with low seat-belt and child restraint use, it is hoped thatthe in ormation and advice contained within this manual will also help countries with higher rates o use to urther improve usage rates, rein orce their campaigns anddirect urther resources towards promotion o increased use.

trategies that work in one country may not necessarily trans er e ectively toanother. Te manual attempts to re ect a range o experiences rom around the world, but does not o er prescriptive solutions. Rather, it is hoped that the manualcan act as a catalyst or local initiatives and actions to improve road sa ety. t providesa base o in ormation that stakeholders can use to generate their own solutions anddevelop advocacy tools and legislation to increase the use o seat-belts and child

restraints that will work with the audiences they are trying to reach.



Executive summary

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Te checklist in ox summarizes the steps needed to implement a programme toincrease the use o seat-belts and child restraints.

1. Assess the current situation using:casualty data;•

usage levels;•

consumer data;•

market data;•

situational data on legislation, penalties, stand-•

ards and en orcement, publicity and education

practices

2. Establish a working group including all key stake-holders needed to develop and promote/advocatethe action plan

3. Develop, manage and promote an action planthat:

is data led;•

is results ocused, with objectives and targets;•

includes resource estimates;•

includes monitoring and evaluation or sustained•

improvement

4. Design and implement the action plan using acombined multisectoral approach Priorities shouldbe chosen on the basis o the assessment andresources available A combined en orcement andpublicity campaign is recommended and the rangeo programme activities includes:

improving legislation;•

increasing penalties;•

improving seat-belt equipment and itting•

standards;strengthening inspection o standards and•

regulations;strengthening the en orcement strategy and train-•

ing police as necessary;developing and delivering a targeted publicity•

campaign linked to and in advance o increaseden orcement;

acilitating other voluntary measures, such as•

employer education and regulation schemes,school, community and driver training programmes,and insurance incentive/deterrent schemes;improving post-crash responses, including rst•

aid, rescue services and emergency medical caresystems

5. Monitor and evaluate the programme. There isa need to:

begin the process at the start when planning the•

programme and collect data be ore implementingthe plan;develop and test the methodology to meet objec-•

tives and measure change in target groups andrelated situations as requently as necessary;collect the data and control quality care ully;•

disseminate the data widely and use results to•

improve the programme

BOX 1: Key steps and programme activities



iIntroduction




I n t r o

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Background to the series o manuals

n , or the rst time ever, the World Health Organization (WHO) dedicated World Health Day to the topic o road sa ety. Events marking the day were held inover countries to raise awareness about road tra c injuries, stimulate new roadsa ety programmes and improve existing initiatives. On the same day, WHO andthe World ank jointly launched theWorld report on road tra c injury prevention,highlighting the increasing epidemic o road tra c injuries. Te report discusses indetail the undamental concepts o road tra c injury prevention, the impact o roadtra c injuries, the main causes and risk actors or road tra c crashes, and proven ande ective intervention strategies. t concludes with six important recommendationsthat countries can implement to improve their road sa ety record ( ox ).

Te report stresses that the growing global problem can be averted with improvedroad sa ety organization and systemwide, multisectoral implementation o demonstrably e ective interventions that are culturally appropriate and testedlocally. n its fh recommendation, the report makes it clear that there are several

“good practice” interventions, already tried and tested, that can be implemented atlow cost in most countries. Tese include strategies and measures that address someo the major risk actors or road tra c injuries, such as:

setting laws requiring seat-belts and child restraints or all occupants o motor•

vehicles;requiring riders o motor cycles to wear helmets;•

establishing and en orcing blood alcohol concentration limits;•

setting and en orcing speed limits;•

managing existing physical road in rastructure in a way that increases sa ety;•

improving vehicle sa ety.•

1 Identi y a lead agency in government to guide the national road tra c sa ety e ort

2 Assess the problem, policies, institutional settings and capacity relating to road tra c injury

3 Prepare a national road sa ety strategy and plan o action

4 Allocate nancial and human resources to address the problem5 Implement speci c actions to prevent road tra c crashes, minimize injuries and their consequences

and evaluate the impact o these actions

6 Support the development o national capacity and international cooperation

BOX 2: Recommendations o the World report on road tra fc injury prevention



Introduction

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A week afer World Health Day, on April , the United ations GeneralAssembly adopted a resolution calling or greater attention and resources to bedirected towards road sa ety e orts. Te resolution recognized that the United

ations system should support e orts to tackle the global road sa ety crisis. Atthe same time, it commended WHO and the World ank or their initiative inlaunching theWorld report on road tra c injury prevention. t also invited WHO, working in close cooperation with the United ations Regional Commissions, to actas coordinator on road sa ety issues within the United ations system.

Following the mandate con erred on it by the United ations General Assembly,since the end o WHO has helped develop a network o United ations andother international road sa ety organizations, now re erred to as the United ations

Road a ety Collaboration. Te members o this group have agreed on commongoals or their collective e orts, and are initially ocusing attention on the sixrecommendations o theWorld report on road tra c injury prevention.

A direct outcome o this collaboration has been the setting up o an in ormal consor-tium consisting o WHO, the World ank, the F A Foundation or the Automobileand ociety, and the Global Road a ety Partnership. Tis consortium is working to produce a series o “good practice” manuals covering the key issues identi ed in theWorld report on road tra c injury prevention. Te project arose out o the numerousrequests to WHO and the World ank rom road sa ety practitioners around the world or guidance in implementing the report’s recommendations.

Te manuals are aimed at governments, nongovernmental organizations androad sa ety practitioners in the broadest sense. Written in an accessible manner,they provide practical steps on how to implement each recommendation in a wayidenti ed with good practice, while also making clear the roles and responsibilitieso all those involved. Te manuals are based on a common template that was usedin a similar document on increasing seat-belt use, developed by the F A Foundationin . Although primarily intended or low- and middle-income countries, themanuals are applicable to a range o countries and are adaptable to di erent levels o road sa ety per ormance. Each manual includes case studies highlighting examples

rom both developed and developing countries.

Te World report on road tra c injury preventionadvocates a systems approach toroad sa ety – one that addresses the road, the vehicle and the user. ts starting pointis the belie that in order to e ectively tackle road tra c injuries responsibilityneeds to be shared between governments, industry, nongovernmental organizationsand international agencies. Furthermore, to be e ective, road sa ety must havecommitment and input rom all the relevant sectors, including those o transport,health, education and law en orcement. Tese manuals re ect the views o thereport; they too advocate a systems approach and – ollowing the principle that roadsa ety should be pursued across many disciplines – they are targeted at practitioners

rom a range o sectors.




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Background to the seat-belt and child restraint manual

Wh was the seat-belt and child restraint manual developed?

Te seat-belt is the single most e ective eature in a vehicle to reduce the severity o injury to the vehicle occupants that results rom road tra c crashes. Article o the Vienna Convention on Road ra c o states: “Te wearing o sa ety belts iscompulsory or drivers and passengers o motor vehicles, occupying seats equipped with such belts, save where exceptions are granted by domestic legislation.”

Tis manual was developed in order to provide essential in ormation on howto increase seat-belt and child restraintusage rates at a national level. t isaimed primarily at low- and middle-income countries, and outlines the process

or increasing wearing rates by examining the need or intervention, e ectiveactions, laws and standards, programme implementation, and the impact o allmultidisciplinary measures. t ollows on rom theWorld report on road tra c injury prevention, which described the evidence that legislating and en orcing mandatoryuse o seat-belts and child restraints is an e ective intervention to reduce injuriesand atalities amongst vehicle occupants. t is one o a series o manuals that provide practical advice in an accessible orm to countries on the steps necessary orimproving their overall road sa ety record.

eat-belts, o course, do not prevent a crash taking place. Tey do, however, play acrucial role in reducing the severity o injury to vehicle occupants involved in a crash.

Who is the manual or?

Te manual is intended to provide relevant in ormation and give guidance to thosecountries that want to improve the use o seat-belts and child restraints, in particularthose that do not, at present, have national legislation covering the tment and wearing o seat-belts, and those that have poor wearing rates.

Te manual targets all key stakeholders. Tese include:

policy-makers•

members o the judiciary•

politicians•

police o cers•

road sa ety and public health practitioners•

transport managers•

employers in the public and private sectors•

vehicle and component (including seat-belts and child restraints) manu acturers•

nongovernmental organizations•

1 eat-belts and child restraints are sometimes collectively re erred to as “occupant restraints”.



Introduction

xx

insurance industry personnel•

school and college teachers•

researchers on road sa ety•

instructors in driving and road sa ety•

motoring and transport associations•

motor vehicle dealers.•

Although aimed particularly at low- and middle-income countries with low levels o seat-belt and child restraint use, it is intended to be use ul or all countries.

What does this manual cover and how should it be used?

What is covered?

Many countries and states have yet to address the possibility o reducing roaddeath and injury through the use o seat-belts and child restraints. ome have onlyattempted to deal with the problem on a very basic level. For these countries, itis recommended that they systematically work through this manual to ensure acomprehensive approach that will increase vehicle occupant sa ety. Te manualhelps users to identi y what actions are relevant to their situation, and provides the practical advice needed to implement the necessary steps. As well as ocusing ontechnical issues, the manual also describes the institutional structures that need to be

in place or a programme o measures to raise seat-belt and child restraint usage ratesto be success ul.

Te manual covers both seat-belts and child restraints. n order to avoid duplicationthe main steps are discussed predominately with re erence to seat-belts, but wherenecessary there is speci c coverage o issues relevant to child restraint use.

Te manual is divided into ve modules, structured as ollows:

Module • explains why interventions to increase seat-belt and child restraintuse are needed. Tis module summarizes the evidence on e ectiveness o seat-belts and child restraints in reducing injury, providing explanations o the bene ts

o use and how an increase in wearing rates can reduce the number o deaths andinjuries taking place.Module • provides guidance onhow to assess a country’s situation regardingseat-belt and child restraint usage . Te module outlines the data needed or anaccurate diagnosis o the problem and or identi cation o gaps and weaknesses inthe mechanisms in place to address it.Module • explains the needto set up a working group and how to use theassessment in ormationto prepare an action plan including objectives, time

rames and targets, prioritizing interventions and estimating resources to raise seat-belt and child restraint usage levels.




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Module • is aboutdesigning and implementing a seat-belt programme . trecommends an approach combining legislation, penalties and standards with arange o interventions, including en orcement, education and publicity. t alsogives guidance on appropriate rescue and medical responses or casualties o crashes.Module • explains how toevaluate a seat-belt programme. t highlights theimportance o building monitoring and evaluation into the project plan as anintegral part o the campaign and identi es the data required.

How should the manual be used?

Te manual is not intended to be prescriptive, but rather adaptable to a particular

country’s current needs. Te manual enables users to adopt a ve-stage process (seeFigure ) or designing and implementing an e ective seat-belt and child restraint

Figure 1 General stages o a seat-belt and child restraint programme: rom assessment to evaluation

Stage 1

Assess the situation(Module 2)

Stage 2

Establish a working group(Module 3)

Stage 3

Develop the programmeand action plan

(Module 2)

Stage 4

Develop and implementindividual activities

(Module 4)

Stage 5

Evaluation(Module 5)



Introduction

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programme. Action plans ( tage ) can be matched to countries’ individual situationsthrough the assessment process ( tage ) and can be continuously adjusted andimproved by monitoring and evaluation ( tage ). Te rst part o Module providesthe crucial in ormation on how to develop an action plan and select the appropriateinterventions. Te second part o Module explains how to plan and implementeach o these interventions e ectively.

Readers are encouraged to read the entire manual; however, once interventions havebeen selected (see priority measures in able . and checklist in able . ), readerscan study the appropriate sections on interventions in more detail to nd out aboutrecommended good practice and see some examples rom other countries.

What are the limitations o this manual?Tis manual is not meant to be comprehensive. t draws upon the experience o itscontributors to identi y practical and e ective steps that can be taken to save livesand reduce the injuries o vehicle occupants by increasing seat-belt and child restraintusage, and thus partly re ects the views o those involved in its production. Teremay well be success ul interventions that are not reported here. imilarly, the casestudies – used to illustrate processes, good practice and practical constraints – arenot exhaustive but merely illustrate ideas presented in the main text.

Te successes o all seat-belt and child restraint programmes are subject to the cultureand environment o a country. Although the advice provided within this manualrepresents good practice, stakeholders should be aware that a programme thatachieves success in one country may not be suitable or implementation in anothercountry. Tere ore an assessment should be made be ore implementation o any programme in order to determine its appropriateness or the target audience.

How was the manual developed?

Tis manual has been produced afer a ull review o the F A FoundationSeat-belt campaign toolkit , published in May (). t is based on a standard template that was developed jointly by the our partner organizations (WHO, the World ank,the F A Foundation or the Automobile and ociety, and the Global Road a etyPartnership), and reviewed externally. Te template was not intended to be rigid, butto provide a loose structure that, where possible, would uni y the manuals in their

orm and approach.

An advisory committee o experts rom the di erent partner organizations oversawthe process o developing each manual, and provided guidance on its content. Asmall editorial committee or each manual then coordinated its technical content.

As part o the original research, a review o relevant literature was undertakenin order to gain as much knowledge as possible rom any previous studies byinternational practitioners. tudies ound and reviewed dated rom to .




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Evaluations were also made o existing technical speci cations, standards andregulations concerning the manu acture and installation o seat-belts.

Additional in ormation was gathered through discussions with epidemiology,education, publicity and manu acturing experts. Clubs a liated to the F AFoundation also provided in ormation relating to campaigns undertaken in theirrespective countries, and questionnaires were sent to the relevant governmentdepartments in countries, covering legislation, penalties, campaigns, technicalspeci cations and standards, and wearing rates. n ormation was also obtained rom WHO highlighting those countries that had or had not implemented seat-belt wearing legislation.

Further literature, in hard copy and electronic ormats, was sought. Tis was againcompared with that used in the original toolkit to identi y any examples o good practice or di ering scenarios and environments. Partners were consulted in orderto obtain case studies that were as diverse as possible, geographically and in terms o income level.

echnical experts were consulted in order to provide additional in ormation that would rein orce the detail o the manual and allow decision-makers to make anin ormed choice about how to implement, manage and monitor campaigns relating to manu acturers, users and the industry as a whole. n ormation was obtained rommedical, technical, manu acturing, policing, education and publicity experts.

Te draf manual was then put through a process o peer review.

Dissemination o the manual

Te manual is being translated into a number o languages, and countries areencouraged to translate the document into local languages. Te manual will bedisseminated widely through the distribution network used or theWorld report onroad tra c injury prevention. Te our partner organizations involved in the manual will plan training workshops to accompany in-country launches o the manual.

Te manual will also be available in PDF, downloadable ree rom the web sites o each o the our partner organizations.

How to get more copies

Further copies o the manual can be ordered by writing to:

F A Foundation60 ra algar quareLondon WC2 5DUnited Kingdom

Or by e-mailing: mail@ a oundation.org



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Re erence

1. Seat belt campaign toolkit . London, F A Foundation, May (http://www. a oundation.org/news/archive/ /Pages/ eatbeltcampaigntoolkit.aspx, accessed October ).



1The need for seat-belts

and child restraints



1.1 Road tra fc death and injury as a worldwidepublic health problem 31 1 1 Worldwide trends in road tra fc death and injury 31 1 2 Types o injuries sustained by vehicle occupants 5

1.2 How seat-belts and child restraints prevent orminimize injury1 2 1 What happens in a crash? 61 2 2 How a seat-belt works 71 2 3 How a child restraint works 7

1.3 Recommended types o seat-belts and child restraints 81 3 1 Seat-belt design 1 3 2 Types o child restraints

1.4 E ectiveness o seat-belt and child restraint use inpreventing death and reducing injury 121 4 1 E ectiveness o seat-belts 121 4 2 E ectiveness o child restraints 151 4 3 Seat-belt wearing rates 161 4 4 Child restraint use rates 19

1.5 E ectiveness o seat-belt and child restraint programmesat increasing wearing rates by vehicle occupants 19

Summary

Re erences




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his module provides the user with background material on why seat-beltsand child restraints are needed. uch in ormation is important in persuading

political leaders and the public to support seat-belt programmes and policies and inincreasing overall restraint use by drivers and passengers around the world.

Te sections in this module are structured as ollows:

. Road tra c death and injury as a worldwide public health problem. Temodule begins by describing the magnitude o the problem o motor vehicle crashes,and the resulting injuries that are sustained by occupants. t explains the globaldistribution o the problem, noting that i present trends continue, many low- andmiddle-income countries are likely to experience an increase in the number o crashesin the near uture as the level o motorization increases.

1.2 How seat-belts and child restraints prevent or minimize injury. Tis sectiondescribes how seat-belts and child restraints protect vehicle occupants and reduce theimpact o a collision.

1.3 Recommended types o seat-belts and child restraints. Te various types o seat-belts and restraints are described in this section.

1.4 E ectiveness o seat-belt and child restraint use in preventing death andreducing injury. Tis section presents evidence rom studies that have evaluated thee ectiveness o seat-belts and child restraints in reducing death and injury.

1.5 E ectiveness o seat-belt and child restraint programmes at increasing wearing rates by vehicle occupants.Tis section shows how legislation oncompulsory seat-belt use coupled with supportive programmes and en orcementhave been e ective in increasing wearing rates.

1.1 Road tra c death and injury as a worldwidepublic health problem

1.1.1 Worldwide trends in road tra fc death and injur

Road tra c injuries are a major public health problem and a leading cause o deathand injury around the world. Approximately . million people are killed each yearin road crashes worldwide, with up to million more injured. Over % o thesedeaths and injuries occur in the low- and middle-income countries o A rica, Asia,Latin America, the Caribbean and Eastern Europe ().

Although the global trends in road tra c atalities over the past – years haveshown an overall increase, the situation varies considerably between di erent regionso the world. n the high-income countries o orth America, Western Europe and



Module 1: The need for seat-belts and child restraints

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Japan, road deaths ell by approximately % between and . n contrast,over the same period road deaths increased in low- and middle-income countriesby between % and %. Data suggest that these trends will continue and that by

road tra c deaths will increase by % in low- and middle-income countries,and decrease by % in high-income countries. Tese gures amount to a predictedglobal increase o % by ().

Te extent to which di erent road users are a ected by road tra c injuries alsodi ers between countries. Te distribution o those killed in various modes o transport in di erent countries is shown in Figure . . O those killed on the roads inhigh-income countries, the majority are drivers and passengers in cars ( ). Te data inFigure . show that vehicle occupants account or as much as % o all road tra c

deaths in the United tates o America, but only – % in countries in outh-EastAsia, where two-wheeler motorized tra c predominates. However, although in low-and middle-income countries car occupants do not comprise the majority o atalitieson the road, experience rom high-income countries suggests that as car ownershiprises so too will the number o vehicle occupant deaths and injuries. Experience romrapidly motorizing nations to date concurs with these trends: or example, in more than new cars were registered every day in China, while in Viet amo cial sources report that new cars are being registered every day (3). Te use o seat-belts and child restraints could prevent many o these deaths and serious injuriesthat occur among our-wheeled vehicle occupants.

Figure 1.1 Road users killed in various modes o transport as a proportion o allroad tra c deaths

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

USA

Thailand

Colombo, Sri Lanka

Norway

Netherlands

Malaysia

Japan

Bandung, Indonesia

Delhi, India

Australia

Motorized two-wheelers Pedestrians Motorized four-wheelers OtherBicyclists

Adapted rom re erence 1




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1.1.2 T pes o injuries sustained b vehicle occupants

Tere are three “collisions” that occur in every crash where occupants areunrestrained. Te rst collision involves the vehicle and another object, e.g. another vehicle(s), a stationary object (tree, signpost, ditch) or a human or animal. Tesecond collision occurs between the unbelted occupant and the vehicle interior, e.g.the driver hits his chest on the steering wheel or his head on the window. Finally, thethird collision occurs when the internal organs o the body hit against the chest wallor the skeletal structure. t is the second collision that is most responsible or injuries,and can be reduced signi cantly by the use o seat-belts and child restraints.

Te most requent and most serious injuries occurring in rontal impacts tooccupants unrestrained by seat-belts are to the head, ollowed in importance by thechest and then the abdomen. Among disabling injuries, those to the leg and neckoccur most requently (, ).

Norway study o head injuries

A study in Norway calculated that head injuries make up some 60% o allinjuries to vehicle occupants The study concluded that drivers and ront seatpassengers who do not use seat-belts su er almost the same percentage o head injuries as non-users in rear seats ( 6 )

Failure to use a seat-belt is a major risk actor or road tra c deaths and injuriesamong vehicle occupants. Passengers who were not wearing their seat-belts at thetime o a collision account or the majority o occupant road tra c atalities. naddition, passengers who do not wear seat-belts and have a rontal crash are mostlikely to su er a head injury.

Although o paramount concern, there is more than just the human su ering associated with non-use o seat-belts. Te nancial burden o increased death and

injury severity can have a major impact on the nances o the government and localcommunities who are paying or the resources that are required to deal with roadcrash victims and their amilies in the afermath o a crash.




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1.2 How seat-belts and child restraints prevent orminimize injury

Tis section describes what happens during a motor vehicle crash and how seat-beltsand child restraints prevent or reduce the severity o injuries sustained.

1.2.1 What happens in a crash?

When a crash occurs, a car occupant without a seat-belt will continue to move atthe same speed at which the vehicle was travelling be ore the collision and will becatapulted orward into the structure o the vehicle – most likely into the steering wheel i they are driving, or into the back o the ront seats i they are rear seat passengers. Alternatively, they can be ejected rom the vehicle completely. eing ejected rom a vehicle drastically increases the probability o sustaining severe serious personal injury or being killed ( ).

Seat-belts as a protection against ejection

The American College o Emergency Physicians advocates the use o seat-beltsas the best protection against ejection in a crash Ejection rom a vehicle isone o the most injurious events that can happen to a person in a crash, with75% o all vehicle occupants ejected rom a vehicle in a crash dying as a resultSeat-belts are e ective in preventing ejections: overall, 44% o unrestrainedpassenger vehicle occupants killed are ejected, partially or totally, rom thevehicle, as compared to only 5% o restrained occupants ( 8, 9 )

Te use o seat-belts and child restraints is one o the most important actions thatcan be taken to prevent injury in a motor vehicle crash. While seat-belts and childrestraints do not prevent crashes rom taking place, they play a major role in reducing the severity o injury to vehicle occupants involved in a collision. An occupant’schance o survival increases dramatically when appropriately restrained.




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1.2.2 How a seat-belt works

eat-belts and child restraints aresecondary sa ety devices and are primarilydesigned to prevent or minimize injury to a vehicle occupant when a crash hasoccurred. eat-belts and child restraints thus:

reduce the risk o contact•

with the interior o the vehicle or reduce the severityo injuries i this occurs;distribute the orces o a crash•

over the strongest parts o thehuman body; prevent the occupant rom•

being ejected rom the vehiclein an impact; prevent injury to other•

occupants ( or example ina rontal crash, unbeltedrear-seated passengers can becatapulted orward and hitother occupants).

A belted occupant will be kept in their seat and thus will reduce speed at the samerate as the car, so that the mechanical energy to which the body is exposed will begreatly reduced.

1.2.3 How a child restraint works

n ants and children need achild restraint system thataccommodates their sizeand weight, and can adaptto cope with the di erentstages o their development.

Te three-point lap anddiagonal seat-belt used byadults is not designed orchildren’s varying sizes, weights, and the di erentrelative proportions o children’s bodies. Forexample, a smaller portion

o a child’s abdomen is ( R i c h a r d S t a n l e y / F I A F o u

n d a t i o n )




8

covered by the pelvis and rib cage, while a child’s ribs are more likely than an adult’sto bend rather than break, resulting in energy rom a collision being trans erred tothe heart and lungs ( ). Consequently three-point lap and diagonal seat-belts maylead to abdominal injuries among children, and will not be optimally e ective at preventing ejection and injury among them.

Appropriate child restraint systems are speci cally designed to protect in ants and young children rom injury during a collision or a sudden stop by restraining theirmovement away rom the vehicle structure and distributing the orces o a crash overthe strongest parts o the body, with minimum damage to the sof tissues. Childrestraints are also e ective in reducing injuries that can occur during non-crashevents, such as a sudden stop, a swerving evasive manoeuvre or a door opening during

vehicle movement ().

1.3 Recommended types o seat-belts and child restraints

1.3.1 Seat-belt design

Tis section describes the main elements o seat-belt design. eat-belt designsshould comply with national or international standards (covered in Module o themanual). Designs that ensure ease o use will serve to increase wearing rates.

Te three-point lap and diagonal seat-belt is the sa est and most commonly usedin cars, vans, minibuses, trucks and the driver’s seat o buses and coaches, while thetwo-point lap belt is most commonly used in buses and coaches. eat-belt standardsset out requirements or the width o webbing and buckles, and the ease o operationand adjustment. n more recent years seat-belts have become integrated into overall vehicle sa ety systems that include such devices as pretensioners, load limiters andairbags.

Tree-point lap and diagonal seat-beltRated highly or e ectiveness and ease o use, the three-point lap and diagonalseat-belt is the most commonly used in cars, vans, minibuses and trucks and in thedriver’s seat o buses and coaches. Te seat-belt tongue clips into the buckle, which inthe ront seats o cars is usually placed on the end o a sti stalk or directly attachedto the seat. A retractor device is included as part o the belt system as this ensuresunnecessary slack is taken up automatically. Tis system allows the occupant toconnect the tongue and buckle using one hand, preventing ejection afer maintaining the seating position o the occupant.




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wo-point lap belt

A two-point lap belt (sometimes called a “single lap belt”) using a retractor deviceis in erior to the three-point lap and diagonal seat-belt described above but can besu cient to maintain the seating position o the occupant, particularly in coaches orbuses.

Crash studies have shown that although the lap belt does ul l the task o reducing ejection, it ails to prevent the occupant’s head and upper body moving orward andhitting the vehicle interior. For the driver, this could result in serious head injuries

rom contact with the steering wheel. However, because o the size and mass o coaches, the severity o injury when involved in a collision with another vehicle isofen minor compared to that other vehicle i it is a car or van.

Single diagonal belt

Te single diagonal design does provide better restraint or the upper body o the wearer than the two-point lap belt, but has been shown to be poorer at preventing ejection and submarining (slipping under the seat-belt).

Full harness

Te ull harness (double shoulder, lap and thigh straps with central buckle device)gives very good protection both rom ejection and rom interior contact. However,it is somewhat cumbersome to put on, and cannot be easily operated with onehand. Tis is an important actor in achieving a high wearing rate, and thus theharness only tends to be installed in vehicles used or motor sport, where drivers andco-drivers are at high risk.

1.3.2 T pes o child restraints

Te sa est place or children aged years and under is in the back seat, properlyrestrained in an approved child sa ety seat. pecially manu actured child restraintsshould be used or children. Tere are a number o di erent types o restraints.

Te main determining actor or choice o a child restraint is the child’s weight( able . ). Older children who are above the height and weight speci cations orusing child restraints require a properly tting three-point lap and diagonal seat-belt when riding in a vehicle.




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Table 1.1 Weight categories o child restraints

Group Description

0 For children o a mass less than 10 kg

0+ For children o a mass less than 13 kg

I For children o a mass rom 9 kg to 18 kg

II For children o a mass rom 15 kg to 25 kg

III For children o a mass rom 22 kg to 36 kg

In ants under the age o year (Group or +)At birth, the in ant head is around a quarter o their total length andabout a third o their body weight. An in ant’s skull is very exible, soa relatively small impact can result in signi cant de ormation o the

skull and brain. Te smaller the child, the lower the orce neededor injury. Te in ant rib cage is also very exible. mpactto the chest can result in a large compression o the chest wall onto the heart and lungs, and some o the abdominalorgans. Te in ant pelvis is unstable and cannot withstandthe orces rom an adult restraint system. n ants require

their own special seat designed to cradle them in a crash,and provide protection rom many types o crashes. ome

in ant seats are convertible; that is, they can revert to a ull childsa ety seat as the child grows older.

A rear- acing child restraint system (sometimes called an “in ant car seat”) providesthe best protection or in ants until they are both year o age and at least kilograms (kg) weight. For the best protection, in ants should be kept rear acing oras long as possible. Te sa est place or in ants is in the back seat in an approved rear-

acing in ant car seat.

Children aged – years (Group I)

Te bone- orming process is not complete until the age o or years,and throughout childhood a child’s skull remains less strong than that o

an adult. A restraint system needs to limit orward head movementin a rontal impact and provide protection rom intrusion in aside impact. A child restraint should there ore distribute thecrash orces over as wide an area as possible. elts and harnessesneed to t well and be properly positioned as designed by




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the manu acturer. Te restraint system should also provide protection rom contact with the vehicle interior in both ront and side impacts.

Te best type o child restraint or young children is the child sa ety seat. Te integralharness secures the child and spreads the crash orces over a wide area. Tis seat willlast them until either their weight exceeds kg or they grow too tall or the heighto the adjustable harness.

Children aged –6 years (Group II)

ooster seats are best used only when a child has outgrown asa ety seat. Tey are designed or weights rom kg to kg.Children should continue to ride in a booster seat until the lapand diagonal belts in the car t properly, typically when theyare approximately centimetres (cm) tall (). ooster seatsraise the seating position o the child so that the adult seat-beltlies properly across the chest, crossing diagonally at the child'sshoulder rather than the neck, and low across the pelvis. the adult belt is too high across the stomach, in a crash seriousinternal injury could result, or the child could submarine under

the seat-belt. Te booster seat has a back and can provide some protection in a side impact.

Children aged 6– years (Group III)ooster cushions without backs are designed or weights rom kg to kg , but

manu acturers are now producing booster cushions with backs that cover the ull kg to kg range. hield booster seats, which have a plastic shield in ront o the

child, o er less protection and should not be used. ooster seats or children aged– years have been shown to reduce injury risk by % compared to seat-belts

alone ( 3).

Recent research suggests that children whose restraints are placed in the centre rearseating position incur less injuries than those placed on the outer seats, although

this is in contrast to some earlier research that ound that the centre seat wasnot a sa er seating position (, ). t should also be noted thatalthough children are best protected when secured in age-

appropriate child restraints, i such restraints are not available,it is still better to use an adult seat-belt on the child than leavethe child unrestrained on the back seat (, ).




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Child restraint systems

Currently, most child restraint systems are designed to be installed using thevehicle’s seat-belt ISOFIX is a system that uses purpose-designed mountingpoints provided in the vehicle to attach the child restraint with a rigid mecha-nism, rather than using the seat-belt to secure the restraint ( 18 ) ISOFIX isincreasingly used in Australia and in Europe, and similar systems have beenadopted in the United States (LATCH) and in Canada (UAS)

1.4 E ectiveness o seat-belt and child restraint use inpreventing death and reducing injury

1.4.1 E ectiveness o seat-belts

ince the s studies conducted throughout the world have shown conclusivelythat seat-belts save lives, when worn and tted correctly. A review o research on thee ectiveness o seat-belts ound that their use reduces the probability o being killed

by – % or drivers and ront seat passengers and by about % or passengers inrear seats ( able . ) ( ). Te impact on serious injuries is almost as great, while thee ect on slight injuries is smaller at – %. More detailed analyses indicate thatseat-belts are most e ective in rontal impacts and in run-o -the-road crashes, wherethe probability o being ejected is high i seat-belts are not worn ().




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Table 1.2 E ect o seat-belts on the probability o personal injury in all types o

collisions (individual e ects)

Injur severit Percentage change in number o injuries

Best estimate 95% confdence interval

Drivers o light vehicles (private cars and vans)

Killed −50 (−55; −45)

Serious injuries −45 (−50; −40)

Minor injuries −25 (−30; −20)

All personal injuries −28 (−33; −23)

Front seat passengers in light vehicles (private cars and vans)

Killed −45 (−55; −25)

Serious injuries −45 (−60; −30)Minor injuries −20 (−25; −15)


Back seat passengers in light vehicles (private cars)

Killed −25 (−35; −15)

Serious injuries −25 (−40; −10)

Minor injuries −20 (−35; −5)


Source: Adapted rom Table 4 12 1 in re erence 7

Te actions o rear seat passengers can a ect both injuries that they themselvesmight incur and those that may be sustained by the driver or ront seat passenger. Anunrestrained rear seat passenger poses a serious threat to any restrained person seateddirectly ahead o them ( ). Tus the use o seat-belts by rear seat passengers couldnot only reduce the likelihood and severity o injury to themselves, but also to driversand ront seat passengers.

Seat-belts and crash atality rates

Seat-belts are approximately 50% e ective in preventing atalities in crashesin which motorists would otherwise die It is estimated that seat-belt use pre-vented about 15 200 deaths in the United States in 2004 I all passengervehicle occupants over 4 years o age in the United States had used seat-beltsin 2004, nearly 21 000 lives could have been saved (that is, an additional5800 lives) ( 21 )




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Cost savings through seat-belt use

Between 1975 and 2000, the United States saved US$ 588 billion in casualtycosts due to seat-belt use The annual savings have increased signi cantly asseat-belt wearing has increased among vehicle occupants For example, theannual economic saving due to seat-belt use in 1975 was US$ 1 5 millionBy 2000, that gure had risen to US$ 49 9 million However, road death andinjury rom non-use o seat-belts still costs American society an estimatedUS$ 26 billion annually in medical care, lost productivity and other injury-related costs ( 8 )

Airbags are a supplemental restraint system,designed to add additional protection to seat-beltsin (primarily) rontal crashes over 13 kilometres perhour (km/h) While airbags have saved many lives,there have also been deaths attributed to airbagsdeploying in crashes that would not have been li e

threatening

Analysis o deaths involving airbags in the UnitedStates showed that nearly all o the people whohave died rom airbag-related injuries were eitherunrestrained or improperlyrestrained ( 22 ) Most o the deaths have beento children and adults o small stature Airbags area passive restraint system,deploying automatically in

some types o crashes I anoccupant is unrestrained,or the vehicle has an airbaginstalled but no seat-belt,it is possible that the occu-pant may come into contactwith the airbag be ore it has ully infated This isalso the case or people who need to sit closer tothe steering wheel as a result o their size Airbagsdeploy at approximately 300 km/h There ore, vehi-cle occupants should ensure that they are restrained

regardless o whether or not a vehicle has an airbaginstalled

Manu acturers should be aware o the potentiallydangerous implications o installing an airbagwithout also tting a seat-belt, and parents should

never position a child in an in ant or child sa etyseat in ront o an airbag Some vehicles have beenequipped with an airbag on/o switch requiringthe driver to vigilantly monitor the airbag status to

ensure maximum protec-tion or passengers Morerecently, manu acturershave designed “second-generation” or “smart”airbags that use sensorsto detect when and at whatspeed to deploy, based oncrash con igurations and

occupant characteristicsThe sa est way to ensurethat children under 12years o age are not injuredby an airbag is to restrainthem in a rear seat Drivers

should sit at least 25 cm rom the steering wheel,and be properly restrained to minimize contact withthe airbag i it deploys The airbag must be rein-stalled ollowing each airbag deployment

BOX 1 1:Airbags, seat-belts and child restraints




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Data rom the North Carolina Trauma Registry wereanalysed to determine the e ect o seat-belt usageon outcome in motor vehicle accidents O 6237persons involved in motor vehicle accidents, data onseat-belt usage were available or 3396 O these,1480 were wearing seat-belts and 1916 were notComparison o hospital charges and outcomes orthe belted and unbelted patients showed that seat-belts could have saved at least 74 lives and US$ 7 2

million There were 135 deaths among the unbeltedpatients (7 0%) and 47 deaths among the beltedpatients (3 2%) Head injury was more common andmore severe in unbelted drivers This is importantbecause head injury is a major actor in mortalitySeat-belt usage is associated with a signi cantdecrease in mortality rate, hospital charges, lengtho stay, intensive care unit stay and ventilator require-ments ( 23 )

BOX 1 2:The trauma care cost o not wearing a seat-belt

1.4.2 E ectiveness o child restraints

Like adult seat-belts, child restraints in cars are intended to keep a child rmlysecured in their seat so that in the event o sudden braking or collision the child isnot thrown against the car interior or ejected rom the vehicle. Te restraint mustabsorb kinetic energy (created by the motion o the child during the crash) withoutitsel injuring the child and must be easy to use.

A review o the e ectiveness o child restraints compared the risk o injury tochildren in di erent seating positions in cars ( ). Children who sit in the rear without child restraints have around % lower risk o being injured than children who sit in the ront without restraints. For children using restraints in both seating positions the risk in the rear is % lower than in the ront ( able . ).

Table 1.3 E ects o child restraints in cars on child’s risk o injury as a passenger

T pe o restraint used

Percentage change in risk o injur

Best estimate 95% con dence interval

Restraining children aged 0–4 years in a orward-

acing child restraint –50 (–70; –30)Restraining children aged 0–4 years in a rear-

acing child restraint –80 (–90; –70)

Restraining children aged 0–4 years with a seat-belt only –32 (–35; –29)

Restraining children aged 5–9 years inappropriate child restraint with seat-belt –52 (–69; –27)

Restraining children aged 5–9 years using seat-belt only –19 (–29; –7)

Source: Adapted rom Table 4 13 2 in re erence 7




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Te e ect o child restraints varies depending on the type o restraint used. A childup to years o age has a % lower risk o injury in a orward- acing child restraintand % lower in a rear- acing seat. Tis compares with injury reduction o only % when an adult seat-belt is worn ( ).

For children aged – years, child restraints reduce injury by %, whereas or seat-belts alone the reduction is only %. For older children aged – years seat-beltsreduce injury by %.

Promoting booster seat use

A systematic review o interventions to promote booster seat use by childrenaged 4 –8 years showed that combining nancial incentives or distribution o

ree booster seats with education demonstrated marked bene cial outcomesor acquisition and use ( 24 )

A review o various United tates studies has shown that child sa ety seats that arecorrectly installed and used or children aged – years can reduce the need orhospitalization by % ( ). Te risk o death or in ants is reduced by %, andthat or children aged – years by – %. O children aged under years, livescould have been saved in the United tates in i all the children had been inchild sa ety seats ( ).

t has been estimated in the United Kingdom that new rules on the use o childrestraints rather than adult seat-belts or children up to cm in height or aged years and above will save over child injuries or deaths every year ( ).

1.4.3 Seat-belt wearing rates

Rates o seat-belt use vary greatly between countries, governed to a large extent

by the type o laws that require seat-belts to be tted in vehicles and cars, andthe laws requiring them to be worn. Rates are also dependent on the degree to which these laws are en orced (see Figure . ). n many low-income countriesthere is no requirement or belts to be tted or used, and rates o use are there orecorrespondingly low. n addition there may be cultural norms that negativelyin uence seat-belt wearing rates, particularly among young adult car occupants.




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Age and seat-belt use

Compared with older drivers, young drivers and ront-seat passengers are lesslikely than older drivers and passengers to use seat-belts while in a movingvehicle ( 28 )

Figure 1.2 Use o seat-belts by car drivers/ ront-seat passengers in urban and non-urbanareas o Finland, 1966–1995

Source: Re erence 1

P e r c e n t a g e o

f d r i v e r s / f r o n t - s e a t p a s s e n g e r s

w e a r i n g s e a t - b e

l t s

0

20

40

60

80

100

1966 1968 1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 199 4

Year

1.1.71

Compulsoryinstallation of seat-belts in

new cars1.9.83

Introduction of “on-the-spot”

nes

1.4.82

Introduction of nes for failure

to wear seat-belts

1992–1994

Information andenforcementcampaigns

1.7.75

Compulsorywearing of seat-belts

(>15 years)Non-urban areas

Urban areas

able . shows the wearing rates or selected countries. Tere is considerable variation in wearing rates, despite legislation on mandatory use in all countries, andrates are generally lower in rear seats than in ront seats. For many o these countries

there is potential or improvement in wearing rates.




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Table 1.4 Seat-belt wearing rates or selected countries

CountrFront seat

driver %Front seat

passenger %Rear seat

%

Albania 52 27 27

Bulgaria 55 55 n/a

Canada 91 90 80

Costa Rica 82 76 48

Croatia 65 27 8

Czech Republic 61 n/a 13

Denmark 84 n/a 58

Egypt 70 45 n/aEstonia 73 75 21

Finland 89 89 80

France 88 97 n/a

Germany 93 95 86

Israel 91 88 34

Luxembourg 74 78 60

Malta 99 93 25

Mauritius 94 84 n/a

Netherlands 90 91 69

Norway 85 90 92

Portugal 88 84 25Slovenia 83 83 40

South A rica 81 50 8

Spain 87 89 52

Switzerland 81 n/a 56

United Kingdom 93 93 83

n/a = not available

Source: UNECE questionnaire and various other published articles (2004)

Fatalities and seat-belt use in European Union

Analysis by the European Transport Sa ety Council estimates that within theEuropean Union seat-belts currently reduce driver atalities by 40% Wearingrates in European countries vary widely rom around 70% to over 95% I allEuropean Union countries were to achieve a 99% wearing rate or drivers, 2400lives would be saved each year ( 29 )




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1.4.4 Child restraint use rates

n many high-income countries the use o child restraints is common – with usagerates up to % – but in other countries they are still rarely used. Choosing andinstalling the appropriate child restraint system is important. Even in countries wherethe use o child restraints is high, such as weden, the United Kingdom and theUnited tates, restraints are requently inappropriately used or misused. For instance,a child may be restrained in the wrong system or its age or weight, or the straps orharnesses may not be adequately secured or entirely lef undone, thus placing thechild at an increased risk o both atal and non- atal injuries ( ).

Appropriate child restraint use may be limited by access and cost, or simply beimpractical because o a large amily size. n addition, a number o decisions about what seat to choose, where to place it and how to install it need to be made by parents. A lack o awareness about the bene ts o appropriate and correctly usedrestraints can jeopardize their e ectiveness. For instance, a study in Greece oundthat the majority o parents ( . %) positioned their children on the back seatunrestrained, while . % o those that did put their child into a restraint did not dothis consistently (3 ).

1.5 E ectiveness o seat-belt and child restraint programmesat increasing wearing rates by vehicle occupants

Te technical e ectiveness o seat-belts and child restraints is well researched and proven. Properly designed and tted restraints save lives. Once seat-belts have beeninstalled in a vehicle, the next objective is to ensure that the vehicle occupants usethem. Tere are a number o ways that this can be achieved. Laws making seat-beltuse compulsory are essential in increasing the wearing o seat-belts in all countries,especially in low- and middle-income countries, where seat-belt wearing rates are low.

o ensure that a much higher level o seat-belt wearing is achieved, a comprehensive programme is required ( ox . ). o be success ul, legislation should be preceded by public in ormation campaigns to raise awareness o the bene ts o wearing seat-beltsand to provide in ormation on the requirements o the law. trong en orcement,especially in the period immediately afer the law is implemented, and continuing publicity and en orcement campaigns are also required, both be ore enactmentand during the initial en orcement period. Although legislation is essential, it willnot achieve high wearing rates unless it is part o a comprehensive programme o legislation, en orcement, publicity, incentives and encouragement.




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Seat-belt legislation and en orcement. Introducingand en orcing a mandatory seat-belt law is neededi rates o seat-belt wearing are to be increased andmaintained This usually requires laws ensuring thatall passenger vehicles are tted with appropriate seat-belts, as well as laws requiring that they are worn Inthe United States, or example, one o the strongestpredictors o seat-belt use among young drivers is astate’s seat-belt law Between 2000 and 2004, rateso seat-belt use were higher and atality rates lower, inevery age group, in all states that en orced a seat-belt

law compared to those that did not ( 31 )

Ensuring that vehicles are ftted with appropriateseat-belts Although rules that require all cars to

be tted with seat-belts are now in place in mostcountries, there is evidence that hal or more o allvehicles in low-income countries may lack properly

unctioning seat-belts ( 32 )

Seat-belt public awareness campaigns Laws man-dating seat-belt use should be backed up by publiceducation campaigns Such campaigns may ocuson young people, and can be used both to increaseawareness and to help make wearing seat-belts asocial norm

Communit -based projects Community projectscan employ parents and peers to encourage youngpeople to wear seat-belts

BOX 1 3:Strategies to bring about increased seat-belt wearing rates

t is important to note that most studies that examine the impact o seat-belt lawshave been conducted in high-income countries, where legislation when introduced isheavily en orced, and is usually preceded by extensive publicity campaigns. Althoughit seems very likely that the introduction o seat-belt wearing legislation in low- or

middle-income countries will decrease atality rates among motor vehicle occupants,there are several unknown actors. Availability o suitable seat-belts and childrestraints is variable across such countries, and the likely level o en orcement is alsoa actor that must be considered. Legislation is most likely to work where seat-beltsare widely tted as standard, where en orcement is comprehensive and where thereis widespread community education on the bene ts o seat-belt use. n low- andmiddle-income countries where police resources are constrained and communityattitudes to seat-belt wearing are not supportive o legislation, e ective en orcementrequires widespread government support.

En orcement o seat-belt law in Argentina

In Argentina a seat-belt law was introduced in Buenos Aires in 1992that raised wearing rates or drivers rom 6% to 32% but, due to lack o en orcement, rates subsequently declined to 13% by 1995 New laws andcampaigns raised the rate to 22% by 2004, but the major gain was madethrough an en orcement e ort that raised the rate to 77% by February2005 I that wearing rate could be achieved and maintained acrossArgentina, 1000 lives could be saved each year ( 33 )




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Programmes that have introduced manu acturing or wearing legislation anddelivered a sustained en orcement e ort, while using publicity and education to raiseawareness and increase compliance, have proven to be success ul in raising wearing rates. able . highlights the achievements o selected countries.

Table 1.5 Increases in ront seat-belt wearing rates in selected countries a terthe implementation o legislation and campaigns

CountrWearing rates (%) prior tolegislation and campaigns

Wearing rates (%) a ter legislationand campaigns

Australia 25 95*

Austria 30 70

Costa Rica 24 82Croatia 50 80

Czech Republic 30 60

Denmark 5 94

Finland 40 93

India 0 5 50*

Japan 37 84

Netherlands 15 86

Norway 10 94

South A rica 33 81*

Spain 25 86

Sweden 20 90

United Kingdom 25 91

* Di ers between states

Mandatory child restraint laws and their en orcement also lead to an increase inthe use o child restraints and have been shown to be e ective at reducing deathsand injuries among children ( ). As with seat-belt programmes, success ullyincreasing child restraint use requires appropriate legislation and en orcement, as

well as community-wide in ormation campaigns. As child restraints are not installed within vehicles like seat-belts but must be purchased and tted by parents it ismore challenging to achieve high usage rates, especially in low- and middle-incomecountries. Module provides more detail on measures to increase child restraint use.




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International recommendations provide strong sup-port or countries to implement programmes thatlegislate or mandatory seat-belt use Some coun-tries may use the international policy environmentand international law as a means o providing thenecessary impetus or developing national policieson seat-belt use International agreements can alsobe used by civil societies to advocate seat-belt lawre orm in their own countries

The World report on road tra c injury prevention rec-ommends that all countries, regardless o their levelo income, ollow several good practices, including“setting and en orcing laws requiring seat-belts andchild restraints or all motor vehicle occupants” ( 1 )

In 2004, the World Health Assembly (WHA) adopted res-olution WHA57 10, which recommends Member States,“especially developing countries, to make mandatoryboth provision o seat-belts by automobile manu actur-ers and wearing o seat-belts by drivers” ( 34 )

The WHA resolution is an international agreementthat can be used by those wishing to infuence policyon seat-belt use as a basis or obtaining political sup-port or this measure In par ticular, such a resolutionhas direct relevance or ministries o health, who, byadopting WHA resolutions, undertake to support theprinciples enshrined in them

United Nations General Assembly resolution A/60/5(2005) “Invites Member States to implement therecommendations o the World report on road tra cinjury prevention including those related to the vemain risk actors, namely the non-use o sa ety beltsand child restraints, the non-use o helmets, drinkingand driving, inappropriate and excessive speed, aswell as the lack o appropriate in rastructure” ( 35 )

United Nations General Assembly resolutionA/62/L 43 (2008) repeated the 2005 resolutioncall or implementation o the World report on roadtra c injury prevention recommendations

BOX 1 4: International support or seat-belt wearing

Summary

Te seat-belt is an e ective sa ety tool that not only saves lives, but also signi cantlyreduces the severity o injury that a vehicle occupant may have sustained i they werenot wearing the device. Around hal o all deaths o ront seat occupants could be prevented through the correct use o seat-belts.

Motor vehicle users make up a high proportion o overall tra c injuries and deathsin high-income countries, and in low- and middle-income countries the proportionis growing as motor vehicle ownership is increasing. t is there ore vital that seat-belt use is increased in these countries to prevent a rapid growth in death and injuryamong vehicle occupants.

Children should use restraints that are suitable or their size. Use o the appropriatetype o restraint or a child’s age, height, weight and physical limitations reducesdeaths o children by between % and %.

Programmes that set and en orce mandatory seat-belt legislation, combined with public education campaigns, are e ective at increasing seat-belt wearing rates andthus reducing injuries and atalities. eat-belt laws that are implemented through primary en orcement are more e ective in increasing wearing rates than lawsimplemented through secondary en orcement.

Tere is strong international support or seat-belt wearing programmes.




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Re erences

1. Peden M et al., eds.World report on road tra c injury prevention. Geneva, World HealthOrganization, .

2. International road tra c and accident database. Organisation or Economic Co-operation andDevelopment (http://cemt.org/ R AD/, accessed ovember ).

3. urning the tide: injuries and violence prevention in China. eijing, China, World HealthOrganization, (http://www.wpro.who.int/ R/rdonlyres/ F – C - A – A-A CAC D / /injurychina.pd , accessed ovember ).

4. Mackay M. Te use o seat-belts: some behavioural considerations. Proceedings o the risk-taking behaviour and tra c sa ety symposium, 19–22 October 1997. Washington, DC, ational Highway

ra c a ety Administration, : – .

5. Hobbs CA, ed. Priorities or motor vehicle sa ety design. russels, European ransport a etyCouncil, .

6. Restraints or adults and children in the back seat o private cars: an estimation o the e ect o alternative regulations. Report A. ordisk ra ksikkerhedsrad, .

7. Elvik R, Vaa , eds.Te handbook o road sa ety measures.Elsevier, .8. Seat-belts. exas, United tates, American College o Emergency Physicians (ACEP),

(http://www.acep.org/patients.aspx?Link denti er=id&id= & d= &Mo= o&acep itle= eat% elt% Fact% heet, accessed ovember ).

9. Te critical need or active ongoing seat-belt use programs in rural areas. ational Highway ra ca ety Administration, (http://www.nhtsa.dot.gov/people/injury/airbags/RuralCrashes/

pages/Critical eed.htm, accessed ovember ).

10. ingvall C. Children in cars: some aspects o the sa ety o children as car passengers in roadtra c accidents. Acta Paediatrica Scandanavica, , uppl. : – .

11. Agran PF, Dunkle DE, Winn DG. Motor vehicle childhood injuries caused by noncrash alls andejections. Journal o the American Medical Association, , : – .

12. Child passenger sa ety program. United tates Department o ransportation, ational Highwayra c a ety Administration ( H A) (http://www.nhtsa.gov/portal/site/nhtsa/menuitem. c d e e bbb a c/, accessed ovember ).

13. Durbin DR, Elliott MR, Winston FK. elt-positioning booster seats and reduction in risk o injury among children in vehicle crashes. Journal o the American Medical Association, ,

( ): – .14. Kallan MJ, Durbin DR, Arbogast K . eating patterns and corresponding risk o injury among

- to -year-old children in child sa ety seats. Pediatrics, , ( ):e –e .15. Lund UJ. Te e ect o seating location on the injury o properly restrained children in child

sa ety seats. Accident Analysis and Prevention, , ( ): – .16. Hertz E. Revised estimates o child restraint e ectiveness.Research ote. Washington DC,

ational Highway ra c a ety Administration, .17. Johnston C, Rivara FP, oderberg R. Children in car crashes: analysis o data or injury and use o

restraints.Pediatrics, : : – .18. ISOFIX and passenger sa ety systems in road vehicles. nternational Organization or

tandardization (http://www.iso.org/iso/support/ aqs/ aqs_widely_used_standards/widely_used_standards_other/iso x_and_passenger_sa ety_systems_in_road_vehicles.htm, accessed

ovember ).




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19. Evans L. a ety belt e ectiveness: the in uence o crash severity and selective recruitment. Accident Analysis and Prevention, , : – .

20. roughton J.Te threat posed by unrestrained rear seat car passengers. RL Report .Crowthorne, United Kingdom, RL Ltd, .

21. Te national initiative or increasing sa ety belt use: Buckle Up America campaign.Eighth Reportto Congress. ational Highway ra c a ety Administration, (http://www.nhtsa.dot.gov/ people/injury/airbags/ th UAReport/index.htm, accessed ovember ).

22. Air bags. exas, United tates, American College o Emergency Physicians (ACEP), (http://www.acep.org/practres.aspx?Link denti er=id&id= & d= &Mo= o&acep itle=Air% ag% a ety, accessed ovember ).

23. Rutledge R et al. Te cost o not wearing seat-belts. Annals o Surgery, , ( ): – .24. Ehiri JE et al. Interventions or promoting booster seat use in our to eight year olds traveling in motor

vehicles. Cochrane Database o ystematic Reviews, ssue , .

25. Zaza , leet DA, Tompson R. Review o evidence regarding interventions to increase the use o child sa ety seats. American Journal o Preventive Medicine, , ( uppl. ): – .

26. ra c sa ety acts 2002: occupant protection. DO H . ational Highway ra ca ety Administration, (http://www-nrd.nhtsa.dot.gov/pd /nrd- / C A/

F / occ acts.pd , accessed ovember ).27. Amendment to the seat-belt wearing regulations. United Kingdom Department or ransport,

(http://www.df.gov.uk/consultations/aboutria/ria/amendmenttotheseatbeltwearin ?page= #a , accessed ovember ).

28. Williams AF et al. eat belt use o high school drivers and their passengers. Journal o ra c Medicine, , : – .

29. Road sa ety per ormance Index Flash 4: increasing seat-belt use.European ransport a ety

Council, (http://www.etsc.be/documents/P % Flash% .pd , accessed ovember).

30. soumakas K et al. Parents knowledge and attitudes about preventing injuries in motor vehicleaccidents in children in Greece.ra c Injury Prevention, , ( ): – .

31. Liu C et al.States with primary en orcement laws have lower atality rates. ra c a etyFacts Research ote, DO H . Washington, DC, ational Highway ra c a etyAdministration, .

32. Forjuoh . ra c-related injury prevention interventions or low-income countries. InjuryControl and Sa ety Promotion, , : – .

33. ilveira AJ.Seat-belt use in Buenos Aires, Argentina: a 14-year-old struggle.Luchemos por la Vida.Paper presented at the nternational Con erence on ra c a ety on Four Continents, Warsaw,

October .34. Road sa ety and health. Resolution WHA . o the World Health Assembly, th session,

May (http://www.who.int/violence_injury_prevention/publications/road_tra c/en/index.html, accessed ovember ).

35. Improving global road sa ety. Resolution A/ / o the United ations General Assembly, thsession, December (http://www.who.int/violence_injury_prevention/publications/road_tra c/en/index.html, accessed ovember ).



2How to assess the situation

in a particular country



2.1 The need to assess the current situation 272 1 1 Understanding the current situation through baseline data

collection 2 1 2 Quality o the data 2

2.2 How to assess the extent o the problem o non-use oseat-belts and child restraints 292 2 1 Assessing the extent o the vehicle occupant injury problem 302 2 2 What are the seat-belt and child restraint wearing rates in

the area being considered? 352 2 3 Why do people not wear seat-belts and use child restraints? 40

2.3 How to assess what is already in place 462 3 1 Who is in charge o road sa ety, and what unds are there or it? 462 3 2 Who are the stakeholders? 482 3 3 Is there a seat-belt use law in place? 492 3 4 Is there a seat-belt and child restraint standard in place? 512 3 5 Have any seat-belt and child restraint programmes been

attempted so ar? 512 3 6 Using the situational assessment to prioritize actions 53

Summary

Re erences




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Module 1 explained why seat-belts and child restraints are needed to reducethe atalities and injuries that are associated with motor vehicle crashes. e ore

designing and implementing a strong seat-belt and child restraint programme, it isimportant to assess the situation and needs in the community, region or country where the programme will be implemented. Tis is ofen called a “needs assessment”.Many o the steps in this process will also be necessary to monitor the seat-belt programme, once it is in place.

Te sections in this module are structured as ollows:

2.1 Te need to assess the current situation. A situational or needs assessment todetermine the extent o the problem is the basis or creating an e ective seat-beltand child restraint programme. n addition, needs assessments are essential orgalvanizing support and obtaining unding or programmes (and are ofen requiredin unding applications).

2.2 How to assess the extent o the problem o non-use o seat-belts and childrestraints. Tis section provides guidance on how to:

assess the extent o the vehicle occupant injury problem;•

measure seat-belt and child restraint usage;•

determine the reasons or lack o seat-belt and child restraint use.•

2.3 How to assess what is already in place.Tis section describes the questionsthat need to be asked in order to collect in ormation on what national processes are

under way in the country or region with regard to seat-belt and child restraint use.o do this, it is necessary to nd out who is responsible or road sa ety, and consider

all those who may have an interest in a seat-belt and child restraint programme.Te module gives guidance on how to collect comprehensive in ormation on theinstitutional and legislative structures that are in place that might have an impacton the programme, and how to nd out about any existing or previous seat-beltand child restraint programmes in the project area, in order to learn rom theseexperiences and to identi y the potential resources ( nancial, personnel andinstitutional) or uture programmes.

2.1 The need to assess the current situation

2.1.1 Understanding the current situation through baseline datacollection

Tose planning a seat-belt or child restraint programme may already have an

understanding o some o the in ormation and issues around restraint use in their



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country or region, and thus may eel they do not need to conduct a situational orneeds assessment. onetheless, conducting a well-planned and thorough situationalassessment is strongly advised prior to starting any new programme. Tis doesnot necessarily imply a prolonged and complicated process, but can mean simplytaking the time to search or and compile all the existing relevant in ormation. Temost important in ormation to collect is data on current use o seat-belts and childrestraints. n addition, although the causal link between restraint use and injuryreduction is generally well known, evidence on injury rates or belted and unbeltedoccupants i available is use ul to support the case or legislation on mandatory use.A situational or needs assessment is essential to obtaining initial and continuedsupport and unding or any programme. t will show the gravity o the problem inthe speci ed location and, once the programme is implemented, the initial resultscan be compared to later evaluations (see Module ) in order to demonstrate thee ectiveness o the programme.

Tere are three main reasons or assessing the situation be ore starting a seat-belt andchild restraint programme.

o identi y• the problem o lack o restraint useand to depictthe scale o the problem . deally, the in ormation gathered will illustrate injury and atality ratesamongst belted and unbelted people; di erences in wearing rates according to age,sex and location; where the greatest need or increasing wearing rates is; the cost o not using seat-belts; and the reasons why vehicle occupants do not use seat-belts.Tis in turn helps set priorities or action.

o provide• evidence or arguments on why restraint use is essential and why itshould be supported. A seat-belt and child restraint programme, in order to besuccess ul, needs the backing o both policy-makers and the public. Accurate data– on actors such as seat-belt and child restraint use and injuries among belted andunbelted occupants in the project area – will help to show what can be gained byimplementing a programme, and provide arguments to convince policy-makersand the general public o the need or a comprehensive programme. Module provided background data on the evidence or the e ectiveness o restraints inreducing deaths and injuries that can also be used in support o setting up a local programme.

o provide• baseline indicators that can be used or monitoring and evaluating a programme. Tis may include quantitative in ormation such as seat-belt wearing rates, as well as qualitative in ormation such as public opinion on seat-belt use, orin ormation on compliance with legislation.

Tese data provide stakeholders with a clear understanding o the current situation inrelation to seat-belt and child restraint use, legislation, manu acturing standards andthe capacity or change. Tey also provide use ul baseline gures against which thee ectiveness o uture actions can be evaluated.

Determining the mechanisms currently in place to increase seat-belt and childrestraint usage can help stakeholders identi y any short alls in legislation or




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implemented campaigns. For example, it may reveal that no en orcement o existing legislation is undertaken.

2.1.2 Qualit o the data

Good data are important in assessing the situation. Tis means data that areappropriate, accurate, complete and reliable. n collecting data, one can also identi y problems in the data system itsel . For example, in collecting data on seat-belt andchild restraint use in a region, it may become clear that the data on seat-belt wearing rates are incomplete. Knowledge o such shortcomings in the data can help setrealistic objectives as part o the programme.

onetheless, in many countries where reporting systems are not well established orcoordinated, some o the necessary data will not be available. Lack o data should notbe used as an excuse or inaction or ignoring a country’s problem o crash injuries.

ome country-level data are always available, no matter how rudimentary these maybe, and they can be used as a starting point to develop a strategy or increasing seat-belt use.

Methods or collecting data will vary and the data obtained will probably alsodepend on the source. Hospital data on crashes and injuries incurred, or instance,may be biased because they only take into account cases that are actually brought tothe hospital. imilarly, police data on crashes will only record those cases the policeinvestigate. However, either o these two sources is a good starting point.Data collection should ideally be led by a person who has experience inepidemiology. Module discusses the establishment o a working group to developa seat-belt and child restraint programme. Te public health expert in the working group is probably the most suited person to take charge o this task.

2.2 How to assess the extent o the problem o non-use o

seat-belts and child restraints

Te next two sections guide users on how to gather the in ormation needed orassessing the situation. Collecting such detailed data on some o these issues willbe an essential part o any seat-belt use intervention, both as a component o the programme itsel and or the purpose o monitoring and evaluation.




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2.2.1 Assessing the extent o the vehicle occupant injur problem

Tis assessment involves examining data on road tra c crashes in order to gauge theextent o the problem with regards to vehicle occupants, and collecting in ormationon injuries among motor vehicle users.

Collecting data on road tra c crashes

Developing appropriate measures to address a road sa ety problem requires accuratedata on the extent o the problem o road tra c crashes, and in particular on motor vehicle crashes and the injuries that result. Te data should be used to highlightspeci c dangers acing motor vehicle occupants, and to emphasize the need or anaction programme.

n ormation will be needed on the incidence, severity and types o crashes. Athorough understanding o the causes o crashes is also important. n ormation suchas locations with an increased risk or motorists, or groups o drivers at increased risk, will be valuable or targeting the programme. For instance, it may turn out that busyurban roads or rural roads are the highest risk areas; young males may be the group

ound to be at special risk, or people driving as part o their work.

o collect these data, the ollowing questions need to be asked:How many injuries and deaths are there as a result o road tra c crashes in the•

project region? ote that it is important or the working group to prede ne the

unit o assessment (see Module ). For example, this may be the entire country, orit may be a particular province or state, or town or community. What is the scale o the problem o crashes involving motor vehicle occupants,•

in terms o the number o crashes and the number o atalities, distinguishing between belted and unbelted occupants?How does this problem compare, in terms o its scale and the burden on society,•

with other local public health problems? Who are those most likely to be unrestrained in crashes?•

What proportion o vehicles have seat-belts tted? n the ront? n the back?•

What are the wearing rates o seat-belts and child restraints in the ront and in the•

back o vehicles?Te indicators to be used here include:

injury data showing severity and mortality rates amongst belted and unbelted•

occupants;the age and sex o drivers and passengers involved in crashes;•

wearing rates by sex, age and seating position;•

the distribution o crashes across di erent road types;•

the age and sex o drivers and passengers involved in these crashes;•

proportion o vehicles by type with tted seat-belts, distinguishing between ront•

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Data rom surveys and interviews on public attitudes and opinions are use ul indetermining reasons or non-use in order to develop e ective interventions.

Locating the required in ormation

ome countries have national data collection systems on road tra c deaths, injuriesand disabilities. ra c police may collect some o this in ormation, but generallysuch data collection results rom collaboration between the police and the transportand health departments. Although tra c crash data systems usually lack detailon the injuries sustained, asking the questions may help to either nd where thisin ormation is available, or at least show that particular data are lacking. this is notavailable, use can be made o other speci c data sources, which are listed below.

Police authorities. n most jurisdictions investigating crashes is the responsibilityo the police. Crash data by severity should be collected in order to provide baselinedata or injury rates prior to a seat-belt campaign. Where reporting rates or injurydata are suspect, atality data alone will provide good evidence on the e ectivenesso seat-belt campaigns. Police records may also provide in ormation on whetherseat-belts were in use in crashes, though these data are not always reliable. uch data will probably also be handled by the country’s tra c sa ety agency or transportationdepartment, so that in ormation rom these bodies should also be considered “o cialdata”.

n practice, ull in ormation on these actors is rarely available, as data may not becomplete. ssues o underreporting in police records exist even in those countries with a good road sa ety record.

Hospital data. n some countries, the health system is the only comprehensivesource o data about road crash injuries. Hospital records are likely to include mainlythe most seriously injured casualties, but they are a use ul source o in ormation onthe distribution o injury types. ince motor vehicle injuries are admitted throughthe emergency or trauma department it might be e cient to begin the search ordata using emergency department records and charts. t is use ul to make periodicstudies o hospital data, either rom a single hospital or a group o hospitals in

an area. y extrapolating a sample o data, an order o magnitude estimate can beobtained o the scale o the problem nationally or provincially. Tese studies shouldextract in ormation on:

the type o injury, or instance the body region injured;•

the nature o the motor vehicle crash;•

the types o injuries that most requently result in death;•

in ormation on those involved in crashes, such as sex, age and occupation.•

Death certi cates. Another source o data is death certi cates or coroner reports,although the in ormation and quantity is limited as the numbers will not includenon- atal injuries. Usually, any physician (not just the coroner) can sign a death




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certi cate, but most jurisdictions keep all death certi cates in one government-runlocation, such as the ministry o health.

Health clinics. ome localities do not have trauma centres or hospitals nearby, andrely on local health clinics or primary care treatment acilities to treat injuries andillnesses. Tese may be suitable sites or collecting basic in ormation on the natureand circumstances o a motor vehicle crash, injuries sustained and seat-belt use.

Employers. Ofen, larger employers collect and retain data on crashes and injuriesto their drivers, especially in occupational driving settings. Looking at employer datacan give a picture o how risky occupational driving can be, and the bene ts (botheconomic and worker-related) o a mandatory seat-belt use policy or occupationaldrivers.

Insurance companies. nsurers, both health and automobile, may be a convenientsource o data. Looking at insurance claims data can yield important insights intocosts o care related to motor vehicle crashes, and the bene ts o wearing seat-belts toreduce health-care claims.

In-depth crash injury studies. Although police and hospital data will providein ormation on injury trends, detailed comparison o the extent and severity o injuryin belted occupants compared with unbelted occupants may only be available romin-depth research. Other sources o data o this kind might be nongovernmentalorganizations, universities, research organizations and insurance companies.

Similar or neighbouring countries. Although no two countries or regions will beidentical in the circumstances and conditions with regard to vehicle crashes, wheredata rom a country are lacking, it can be help ul to examine what data are available

rom similar or neighbouring countries. uch data can be used in support o a seat-belt programme in the country o interest, provided that a clear statement is madethat it has been assumed that the two countries are similar with respect to certain

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The United Kingdom’s Co-operative Crash InjuryStudy (CCIS) is one o Europe’s largest car occupantinjury causation studies Multidisciplinary teamsexamine crashed vehicles and correlate their ndingswith the injuries the victims su ered to determinehow car occupants are injured The investigationteams monitor details o all the injury car crasheswithin their geographical areas All atal and seriousinjury crashes and a random sample o slight injurycrashes are selected Each year a total o 1176vehicles are examined Details o the occupants’injuries are encoded into the Abbreviated Injury Scale

(AIS) ormat to allow or database analysis acrossthousands o crashes Questionnaires are sent tooccupants and provide very use ul supplementaryin ormation The vehicle in ormation and occupantinjury details are correlated to determine, wherepossible, the causes o injury This in ormation iscompiled into a complete crash record that can beused by researchers

The CCIS database has been used to estimateseat-belt e ectiveness and the additional e ects

o airbags ( 1 )

CASE STUDY:Data collection through crash injury study, United Kingdom

Collecting data on injuries

Te protection provided by seat-belts increases with crash severity. Te e ect ismost marked or prevention o atalities, but also or the most serious injuries. eat-belts reduce the incidence o ejection rom vehicles, and the injuries due to striking the windscreen. Te CC database shows that % o unbelted occupants whodied when their cars rolled over had been ejected, compared with % o beltedoccupants ( ).

Understanding the e ects o a seat-belt programme will include the need to collectdata on injury severity and, i available, injury type. Te latter will be help ul in providing in ormation on how the range o injuries (by severity) has changed, as wellas the number o injuries. However, the high e ectiveness o seat-belts means thateven in the absence o detailed injury records, overall numbers o casualties can be areasonable measure o the bene ts. A note o caution is necessary where tra c levelsare increasing rapidly, as any subsequent increase in crashes may distort the measureo the estimate o the e ect o seat-belt wearing.

o collect these data, the ollowing questions need to be asked: What proportion o motor vehicle crashes involve atal injuries? What is the•

distribution o injury by body region, by injury score or by severity, as de nedby the police? ome injury scores used by medical pro essionals include theAbbreviated njury cale (A ), Maximum Abbreviated njury cale (MA ),

njury everity core ( ) and Probability o Death core (POD ). What are the economic and social impacts o these crashes and injuries on the•

country’s resources? What is the geographical distribution o motor vehicle occupant injuries within•

the region?




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Are there particular population groups in the region that are at increased risk o •

injuries resulting rom motor vehicle crashes, or instance men, women, young people, ethnic minorities or a particular occupation? What other in ormation is collected on those injured as a result o motor vehicle•

crashes? For example, are those injured generally the drivers or passengers, and dothey usually own the vehicle?

s there in ormation on seat-belt and child restraint use among motor vehicle crash•

victims? available, this will allow a comparison o outcome o crashes involving motorists with and without restraints.

able . indicates some o the more commonly used sources o data on injuries, andgives other potential sources o data on injuries.

Table 2.1 Possible sources o data on injuries, according to severity o injury

No injur Mild Moderate Severe Fatal

Household (community) surveys

Health clinic records

Family doctors’ records

Emergency room records

Ward admission records

Intensive care unit admission records

Death certi cates

Other potential sources o data on atal andsevere injuries are:

For atal injuries:autopsy/pathology reports•

police reports•

For severe non- atal injuries:hospital inpatient records•

trauma registries•

ambulance or emergency medical technician•

records

Additional sources o data on specifc t pes o injur are:

For motor vehicle injuries:automobile insurance company records•

police tra c accident reports•

department o transport reports•

For occupational injuries:workplace records•

labour inspector or national sa ety records•

national insurance schemes/workers’•

compensation bureaurehabilitation centres•

Source: This in ormation is extracted rom the Injury surveillance guidelines (3 ).




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2.2.2 What are the seat-belt and child restraint wearing rates in thearea being considered?

An accurate assessment o the current situation with regard to seat-belt tment (thenumber o vehicles tted with seat-belts or all seating positions) and overall seat-beltand child restraint use will provide any country or state with a number o baseline

gures that uture programmes will aim to improve. Tere ore, all subsequentassessments become indicators o success. n relation to a programme designed toincrease seat-belt usage, it is vitally important to determine current wearing rates andto examine existing mechanisms in place that promote the use o the sa ety device.

Assessing the proportion o motor vehicle users wearing seat-belts will be animportant actor to consider in arguing or a seat-belt programme. Tis means asking the ollowing questions:

What is the proportion o seat-belt use among vehicle occupants nationally•

(or in the project area)? Tis rate (percentage o belted occupants by seating position) should also be used as a baseline indicator against which to evaluate the programme’s e ectiveness. What types o people are not wearing seat-belts? Can a breakdown be arrived at•

in terms o age, sex, whether the person is a driver or passenger and purpose o the journey? What is the cost o the non-use o seat-belts, in terms o injuries sustained by•

motor vehicle users involved in crashes?

Where will these data come rom?

Data on seat-belt use may be available rom the ollowing sources: police records•

records o national or local health authorities•

national transportation agency records•

research studies and surveys.•




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Road tra c injuries are a major public health problemin Malaysia They constitute the second leading causeo burden o mortality Vehicle occupants constitutedabout 18% o road atalities in 2003 Legislation orseat-belt use in the ront seats was introduced in1978 The usage o seat-belts in both ront and rearseats was studied using similar methodology in thesame urban and rural districts in 1995 and 2006

Factors a ecting seat-belt use included age, sex,ethnic group and location o road There was an

increase in the usage o seat-belts as age increasedup to the age o 69 and a slight decline a ter the ageo 70 among the ront seat occupants There was alow use o seat-belts among adolescents, with only50% o adolescent drivers and 76 5% o adolescentpassengers in the ront seat using seat-belts com-pared with the overall rates o 84% (rural) and 87%

(urban) A higher percentage o emale drivers (91%)wore seat-belts than male drivers (82%) I the driverwas belted, there was a higher probability that the

ront seat passenger was belted Usage o childrestraints was minimal, and rear seat-belt wearingwas also very low, 10% on urban roads and 3% onrural roads

Over the 10-year period seat-belt use has showna slight increase on urban roads, and a largerincrease, rom a lower rate, on rural roads, so that

the urban/rural di erence has narrowed Thoughthe law was introduced nearly 30 years ago, it needsto be en orced Usage o child restraints shouldbe promoted A signi cant number o deaths andunnecessary disability can be prevented through theimprovement o seat-belt use ( 4 , 5 )

CASE STUDY: Seat-belt use in Malaysia

Observational surveys o seat-belt use

accurate current in ormation on the extent o seat-belt wearing is lacking it will benecessary to carry out observational surveys. Tese may be concentrated in particularregions or at particular locations. ince an increase in the usage o seat-belts will be akey objective o any campaign, it will be important to establish a reliable regime ormeasuring and monitoring seat-belt use on a regular basis. Tis does not have to be anationwide survey, but it should ideally cover a range o road types and locations.

ites should be selected such that all road types are represented so that as ar as possible correlation may be made between urban and rural roads, motorways andunclassi ed roads, built-up areas and non-built-up areas, and so on. ites should beassessed or the ease with which they allow the survey sta to observe and record theuse o seat-belts and child restraints by vehicle occupants. For example, sites wheretra c lights are installed allow survey sta time to view vehicle occupants clearly.Tis helps to ensure that results can be generalized to represent di erent vehiclesand di erent journeys. Tis need to observe the car occupants is a limiting actor incarrying out surveys on high-speed roads such as motorways.

Te sites selected or observation can depend to some extent on the survey sta .Compromises can be made on the data being nationally representative to ensurequality o data over quantity o data. Tere ore, it is better to accept surveysconducted in one or two smaller locations where the researcher can rely on quality o data than try to blanket large parts o the country or state and receive inaccurate data




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rom unreliable survey sta . o ensure consistency in data, researchers should tryto use the same sites or every subsequent observation. Te case studies below romGhana and the United Kingdom give examples o procedures that have been used.

The rst national study on seat-belt compliance inGhana took place in 2006 as part o the Drive toLive Programme Seat-belt usage was measured ina series o observations under taken in the country’sregions with the highest crash rates The study (sam-ple size 12 000) also recorded motorcycle helmetusage, mobile phone usage and spectacle wear-ing The data were collected prior to a road sa etycampaign that encouraged seat-belt wearing andswitching o phones while driving A set o “a ter”campaign data will be collected, which will also beused to in orm a national seat-belt campaign

Observations were made at the point o sale oruel ( uel stations) The surveys were conducted

between 07:00 and 09:00, and between 16:00 and18:00, corresponding to the peak periods or retailsales, and included collection o both weekday andweekend data

Survey supervisors were chosen rom subcontrac-tors regularly used by a company specializing insurveys The supervisors trained regional enumera-tors to conduct the surveys at the uel stations Twoenumerators were assigned to each uel station (withthe exception o two sites where our were used) torecord the ollowing in ormation:

seat-belt usage (driver and passenger)•

usage by ve vehicle classes•

motorcycle helmet usage•

use o mobile phone while driving•

spectacle wearing•

These observations indicated about 40% complianceoverall with seat-belt usage laws, with the highestrates amongst car drivers (up to 50%) and the lowestrates amongst truck drivers (less than 20%) ( 6 )

CASE STUDY: Assessment o seat-belt wearing rates, Ghana




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In the United Kingdom, surveys o seat-belt use havebeen carried out every year since October 1988in April and October, when journeys are less likelyto be a ected by summer holidays and adverseweather Initially only two areas, Crowthorne andNottingham, were surveyed, but in 1998 the cover-age was extended and by 2002 urther summersurveys in 10 additional areas were carried outTeams o three observers are used and observationsare made between 08:30 and 17:30 in eight hal -hour sessions All observations are made in daylightto ensure visibility o seat-belt use

Two team members observe the occupants o passing vehicles, including their age, sex and seat-belt use Their observations are recorded using ahand-held computer, with one electronic orm beingcompleted or each car that is surveyed The thirdteam member counts the number o vehicles passingduring each session

In order to be able to look into cars to record theseat-belt use o rear seat passengers, only station-ary cars are observed, so survey sites are located

wherever possible at junctions with automatic tra csignals When the tra c stops at the approach tothe junction, the pair o observers proceeds alongthe queue o vehicles, observing the occupants o each stationary vehicle in turn When the queuestarts to move, they return to the junction and wait

or the tra c to stop once more be ore restartingthe process

A clear sampling strategy is required For example,at a tra c signal location:

When the signal turns red, observe the rst car1that stopsAs time permits, observe in strict order any sta-2tionary vehicles queuing behind the rst

When the lights change, suspend observation until3the next red period

The survey sites are chosen so as to be representa-tive o all types o road and tra c However, theneed to observe stationary vehicles means that it isimpossible to make observations on motorways, andthere are ew suitable sites on rural roads ( 7 )

CASE STUDY: Seat-belt wearing survey procedures, United Kingdom

ox . describes how to set up an observational study. A sample seat-belt wearing observation orm is given in Appendix .




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Even i detailed and comprehensive data are lacking,it should be possible to conduct a simple observa-tional study to obtain a good estimate o seat-beltuse Simple counts o drivers and passengers usingseat-belts, at particular locations and at di erenttimes o the day, will provide a rough estimate o howmany motorists are using seat-belts and will later beo use in developing actions to be taken

Because o cost, this type o study is o ten done on asmall scale I it is already known that a high propor-

tion o crashes and injuries occur on particular roadsor in particular areas, it is recommended that thestudy be carried out in those high-risk locations

This observation method or calculating seat-beltwearing rates in a population could be used or datacollection in situational assessment, as well as inan experimental or quasi-experimental evaluationdesign (see Module 5)

Planning period

Be ore conducting an observational survey, the tar-get population should be clearly de ned in terms o

who they are, where they live and over what periodo time data will be collected Detailed road mapsand data on tra c volume and estimated popula-tion prevalence o seat-belt use rom other sourcesshould be collected or the area o interest

Develop a data collection protocol

This is a detailed written document describing theapproach that will be used to collect data It includeswhat will be done, how it will be done, who will do itand when it will be done

Develop data collection instruments

These include a orm or set o orms used to collectin ormation (e g questionnaires, interview sched-ules) Training material should also be developed orsta carrying out roadside observations

Sampling

The observed population should be representativeo the population o interest in the target area Thismeans that a random sample o the populationshould be observed Although non-random sam-ples may be more easible in certain situations,

or example observations made at uel stations or

outside schools, consideration should be given tohow generalizable or representative the results romsuch selective samples would be

I the aim o the study is to document seat-beltwearing in a particular geographical area, then allroad types should be included in the design o thestudy Seat-belt wearing may di er across di erentroad types; or example, drivers may be more likelyto wear seat-belts on highways than on local roadsThe sampling rame should there ore be designed

such that it ensures adequate counts to enablean estimate o seat-belt use across di erent roadtypes, and also ensures a mix o roadway types, vol-umes and locations (urban, suburban and rural)

All possible roadway segments should theoreticallybe eligible or sampling Depending on the size o the target area, the sampling rame may be dividedinto two or three stages For example, to meas-ure helmet use in a province, three stages may beemployed:

Random selection o primar sampling units•

(e.g. the district or equivalent). The numbero selected primary sampling units should becalculated in proportion to the estimated vehi-cle kilometres travelled (VKT) or each samplingunit For example, i the VKT is low in one district,then proportionally ewer sampling units wouldbe selected rom that district than or one withhigher VKT I VKT is not available by district, theprimary sampling units may be selected usingdistrict populationRandom selection o roads• within each pri-mary sampling unit, ensuring all road types arerepresented

Random selection o observational sites•

on theselected roads

Number o sites

The actual number o observational sites willdepend largely on unding and other logisticalissues I unding is limited it may be more practicalto make a greater number o observations rom asmaller number o sites However, consulting a stat-istician to help determine the appropriate numbero sites to give a statistically precise estimate isrecommended

BOX 2 1:Measuring seat-belt wearing rates: an observational study

Continues…




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2.2.3 Wh do people not wear seat-belts and use child restraints?

A seat-belt and child restraint law is unlikely to be success ul i people do not obeyit, or understand the reason or it, or are unaware o it. imilarly, i vehicles are not widely tted with seat-belts, or child restraints are di cult or expensive to obtain,use rates are likely to remain low. Once seat-belts are available it is important to assessattitudes to seat-belt wearing in order to provide targeted in ormation to support

Site selection

Ensure that observational sites are selected ran-domly rom all available sites This may be doneby creating a numbered grid, overlaying it on a mapand randomly selecting sites rom the grid Exactobservation sites should be determined accord-ing to the planned protocol be ore conducting theobservations

Whenever possible, the observation sites should benear intersections where cars slow down, pre erablyin the absence o a police o cer For example, sites

may be selected at signalized intersections wherevehicles are stationary and observations o seat-belt wearing are easier to conduct

Narrow roads are better or observing passing tra -c; on wider roads, observations may be taken on

one side o the road only, or tra c passing in onedirection

Predetermined protocol

The predetermined protocol should allow or varia-tions in methods or observations or site selectionI tra c volume is too heavy at a particular site

to accurately record in ormation, the protocol maystate that one observer should observe occupantsin the ront seats only, while the other observes rearseat passengers Along with direct observationsrecorded by observers, a video camera may be usedto record tra c fow at sites with heavy fows andwhere tra c travels at high speeds

Each site that does not satis y the selection criteriashould have another alternative site on the sameroad, or example i the original site or time selectedis unsuitable due to inclement weather (e g heavyrain), i police are in attendance at a particular site

or i observations may not be made sa ely at a site(e g due to roadworks)

Seat-belt observations

Project leaders should take sa ety into accountwhen planning observational work and seek to mini-mize any likely measurement error

Observers should be trained be orehand to removeany possible bias Consider where training takesplace, how it is conducted, and who delivers itProduce a written guideline or observers and othersinvolved in the evaluation and ensure that protocolsare adhered to

Observations may be made by two or more trainedobservers Observations may then be later com-

pared to assess level o agreement betweenobservers

Identi y a sa e, convenient location rom which tomake observations For sa ety and security reasons,observers should work in pairs and they should wearrefective vests

Observations should be made or a predeterminedperiod o time Time periods should be the same ateach site to be able to make comparisons betweensites

Observations o seat-belt use may include such

categories as age, sex, seating position and seat-belt present but not worn Clearly, depending on thevolume and speed o tra c at observation sites, itmay not be practical to observe and record morein ormation than whether a seat-belt is worn or notworn (e g estimation o age o car occupants maybe too di cult unless this in ormation is gatheredthrough reviewing video ootage)

Repeating measurements a ter the intervention

Repeat observations should be made by the originalobservers using the same protocol on the same

days and times and at the same sites as measure-ments made be ore the programme

Continued rom previous page




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legislation and campaigns. Child restraints, because they are an additional cost, mayrequire campaigns that provide them ree, on rental, or at low cost.

Public attitudes to seat-belt use

t is use ul to know how people regard road sa ety generally, and their attitudesto seat-belt wearing in particular. Tis in ormation can help shape a seat-beltuse programme and help decide how much should be invested in raising publicawareness about the bene ts o seat-belts. Te goals o a programme will determine which groups should be surveyed and the questions to be asked. Tey may includeasking the ollowing questions:

What are people’s attitudes to road sa ety generally?•

Do people understand the bene ts o wearing a seat-belt? Public attitudes on seat-•

belt use and seat-belt laws can there ore also serve as a baseline indicator. What is the level o public awareness o the bene ts o seat-belts?•

Why don’t people wear seat-belts? For example, i it is ound that motorists have•

a negative attitude towards wearing a seat-belt, or i they are unaware o the lawsor o the e ectiveness o seat-belts against injury, then the programme needs toaddress these issues. Who are those most resistant to using seat-belts? Apart rom gauging the public’s•

knowledge and attitudes, this type o in ormation can also help identi y whichgroups are most resistant to using seat-belts, so that the programme can targetthem to change their attitudes and behaviour. n ormation on variables such asage, sex, occupation and ethnicity would there ore need to be collected.

For child restraint programmes, similar questions should be asked o parents andcaregivers about their attitudes towards child restraints with the added componento cost as a barrier.

Where will these data come rom?

Data o this type may have been collected as part o a previous seat-belt programme(see section . . ). Tere may also be studies conducted:

by market research rms;•

by universities, nongovernmental organizations or other agencies working in road•

sa ety.

such data are not available, it might be use ul to conduct a public opinion surveyto collect this in ormation. the programme is still being developed, there are likelyto be time and budget constraints. Tere ore, only a preliminary survey is suggestedat this stage, and a more detailed one can be undertaken later. n a preliminarysurvey, it is most use ul to ocus just on the geographical area and population groupestimated to have the highest risk.




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Some studies have ound that there is a lack o aware-ness o the risk to passengers in rear seats in carsthat contributes to lower seat-belt wearing rates Forexample, a telephone survey o 1148 Israeli adults

ound that there was a higher perceived need to wearseat-belts in the ront than in the rear, and wearingrates in the rear were 35% higher among respondentswho believed that they were necessary ( 8 )

A survey o parents with children aged under 11 yearsin the United Kingdom was carried out to assess

parents’ knowledge and use o child restraints Only62% said that their child always or usually travelled ina child restraint The use o restraints was highest orchildren aged 0–3 years, and lowest or those aged10–11 years Nearly hal the sample thought that itwas sa e to start using an adult seat-belt betweenthe ages o 7 and 9 years, showing ignorance o thelegal requirement and o the reasons or using a childrestraint ( 9 )

BOX 2 2:Lack o awareness o risk

In Oman wearing a seat-belt is compulsory in theront seats but not in the rear The use o seat-belts in

1066 cars entering a university and hospital campusin Oman was observed to determine the degree o seat-belt wearing in the rear A seat-belt comply-ing with local tra c regulations was being worn by90% o drivers and 81% o ront seat passengersHowever, only 1 4% o back seat passengers worea seat-belt Only 4% o children under the age o

5 years were strapped in a child restraint and only17% o children aged 5–12 years were strapped inA third (34 6%) o children under 5 years o age weresitting in the ront seat In cars with child occupants,40% o the time parents wore seat-belts but thechildren did not Occupants con ormed to the lawbut behaviour indicated a lack o awareness o thedangers o not wearing seat-belts, especially in thecase o children ( 10 )

CASE STUDY: Survey o rear seat-belt use, Oman




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Some reasons given or not wearing seat-belts or usingchild restraints

The ollowing examples o reasons given or not wearing seat-belts or usingchild restraints have been collected rom studies in di erent countries:

Seat-belts are uncom ortable or inconvenient•

Motorists worry that a seat-belt might trap them in a burning car or under•

water ollowing a crash .

Drivers think that they can avoid crashes because they are highly skilled•

Passengers who put their seat-belts on are seen by drivers as criticizing•

their driving

Motorists think that it is better to be thrown clear a ter a collision•

Pregnant women don’t have to wear seat-belts•

It is not necessary to wear seat-belts or short trips around town at low•

speeds

Sitting in the rear o a car is sa e without a seat-belt or child restraint•

Children don’t like being strapped in•

It is sa e to hold a child on the passenger’s lap•

Child restraints are too expensive•




44

M th: Seat-belts are uncom ortable orinconvenient.

Fact: People quickly become used to wearing seat-belts and once wearing becomes a habit there isno discom ort or inconvenience The imaginarydiscom ort or inconvenience o wearing a belt the

rst ew times in no way compares to the seriousdiscom ort and inconvenience o motor vehicle crashinjury Newer seat-belts are made so that com ort-able movement is possible but they will still lock up

in sudden stops or crashesM th: Drivers in airbag-equipped vehicles don’tneed to wear seat-belts.

Fact: Airbags provide supplemental protection inrontal crashes by protecting the head and chestrom hitting the steering wheel or dashboard, but air-

bags will not help in a side or rear impact or roll-overcrash An airbag by itsel reduces the risk o dying byonly 12%, whereas a seat-belt reduces atality risk by45–60% ( 11 ) Motorists should wear a seat-belt orprotection in all types o crashes

M th: Wearing a seat-belt might lead to gettingtrapped in a burning car or caught in one underwater.

Fact: Less than 1 out o 200 tra c-related incidentsinvolve re or water submersion The greatest dangeris with the impact that precedes the re or submer-sion in water I a car occupant is not using a seat-belt,it is very likely that they will be knocked unconsciousor severely injured Chances o escape are 3 to 5times better while wearing a seat-belt ( 12 )

M th: It is better to be thrown clear o a car in acollision.

Fact: Being thrown rom a vehicle is our times morelikely to lead to atal injury in a crash, and threequarters o people who are thrown rom the car arekilled The orce o an impact can throw someonenearly 50 metres, or 15 car lengths Seat-belts alsoprevent a car occupant’s head rom smashing intothe windshield, which could cause spinal damageThe best bet in a crash is to stay inside the vehicle,securely held by the seat-belt ( 12 )

M th: Seat-belts can hurt ou in a crash.

Fact: Properly worn seat-belts seldom cause injuriesI they do, the injuries are usually sur ace bruisesand are generally less severe than would have beenthe case without any belt Studies have consistentlyshown that injuries in most serious crashes wouldhave been much more severe had seat-belts notbeen worn

M th: Seat-belts are unnecessar at low speedsand on short trips.

Fact: O road crash casualties who were notrestrained, 70% were travelling at less than 50 km/h

A collision at 50 km/h has the same e ect as all-ing rom the ourth foor o a building Two thirds o crashes happen less than 15 km away rom home(13 )

M th: Wearing a seat-belt in the back is notnecessar .

Fact: When a crash happens an unrestrained pas-senger in the back seat will be propelled against the

ront seat with a orce o several tonnes, crushing theront seat occupant ( 13 ).

BOX 2 3:Some common myths about seat-belts

Data on availability and cost

Te extent o tment o seat-belts in the vehicle eet needs to be assessed in order toestablish their availability. t will be important to establish the proportion o vehiclesin which seat-belts are tted, showing ront and rear seats separately.

Data on seat-belt tment may be available rom:government data on vehicle registrations by date o vehicle registration•

vehicle manu acturers, retailers or importers•




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2.3 How to assess what is already in place

t is important to assess what laws and regulations on seat-belt use exist in the projectarea, how they are implemented and whether or not they are en orced. For example,i despite a law mandating seat-belt use among car users and a de ned nationalseat-belt standard the seat-belt wearing rate is low and many vehicles do not haveseat-belts that con orm to regulations, it would be a air indication that the laws andregulations are not working, or that the en orcement o these laws and standards isinadequate.

Assessing what is in place in a country with regard to existing or previous seat-

belt programmes will help to identi y the key organizations or people – withingovernment, in the private sector and in civil society – that should be involved ina seat-belt or child restraint programme. Tey will also point to the main sourceso potential political and nancial support. As mentioned, this assessment can beconducted at di erent geographical levels (e.g. country, province or state, town orcommunity) and this should be agreed upon be ore starting.

Te areas described in the ollowing sections need to be examined.

2.3.1 Who is in charge o road sa et , and what unds are there or it?

Describing the general situation in the country is a rst step to assessing the situationand whether there is a place or a seat-belt programme. How such a programme isthen implemented will depend on the country’s political system. t is also importantto consider whether existing laws encourage seat-belt use, and whether there are

unds set aside or road sa ety programmes that could include seat-belt use initiatives.Te ollowing urther list o questions will help ormulate an overall picture o thesituation.

s there a centralized, regional or ederal system o government? s there provision•

in the constitution or in national laws or decentralization? so, to what extent dolocal authorities engage in decision-making and making unds available? Which are the main government departments – such as those o transport, health,•

justice and the police – involved in road sa ety decision-making and what role doeseach department play? What is the current budget or road sa ety in the country? Are there priorities in•

the budget or uture improvements in the eld o road sa ety? Are there undsthat might be accessed or a seat-belt programme?




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ongovernmental and private organizations that could contribute to a seat-belt programme include:

international organizations and unding agencies, such as WHO, the World ank,•

the Global Road a ety Partnership, the F A Foundation, and other bodies withroad sa ety expertise, as well as those with unding capabilities; private consulting rms;•

domestic nongovernmental organizations, including road sa ety groups and•

motoring clubs;manu acturers and distributors o motor cars;•

major employers, particularly where sta use cars in their work, and on journeys to•

and rom home.

Many countries have a national road sa ety policy or plan providing a strategicoutput on delivering better road sa ety. Tere are also many local-area projects withspeci c aims and objectives. n order or seat-belt programmes to have the greateste ect, a coordinated approach should be taken. Tere ore, local-area initiativesshould be encouraged to complement the programme established and delivered at anational level.

Te importance o linking seat-belt and child restraint programmes to national policies and action plans cannot be overstated. Tis con rms commitment tothe programme and aids its implementation. t will also identi y clear targets orsuccess and provide the direction required to achieve the aims and objectives o a

programme.ational campaign organizers should aim to acilitate coordination by providing

local campaign organizers with adequate warning o initiatives, possibly througha published calendar, in order to intensi y the e ect o the road sa ety message.

ational launches o campaigns can also help to bring about a realization that thereis a coordinated drive to increase seat-belt use.

igni cant results cannot be achieved simply by initiating a national campaign.t requires the assistance o local practitioners in delivering and rein orcing the

message. Government agencies are more likely to have the unds to produce resources

and expensive national advertising. Local-level practitioners are in a better positionto distribute resources to the target audience at ground level to rein orce the nationalmessage. Local initiatives may also be guided by targets established at a nationallevel. Tese are more likely to be aimed at reducing road death and injury in general;however, the plan or strategy should de ne how these casualty savings should bemade. Tis may include increasing seat-belt wearing rates.




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2.3.2 Who are the stakeholders?

A stakeholder analysis sheds light on the social environment in which the policy will be developed and implemented. ts primary unction is to identi y all possible partners who might have an interest in addressing seat-belt and child restraint use,including those who might initially oppose e orts to increase seat-belt use or tomandate seat-belt wearing in the region. Potential stakeholders include governmentdepartments, nongovernmental organizations and institutions that will be a ected(positively or negatively) by the new law or standards, local communities, ormal orin ormal groups, as well as individuals (e.g. representatives o work orces, victimso crashes). takeholders might also include vehicle manu acturers who might bea ected by a new law, regulators, industry bodies and associations, importers and

exporters.Te second important unction o the analysis is to examine the remit o all o thestakeholders, and to understand the relationships between them. A care ul analysisshould be made o the in uence, importance and interests o all major stakeholders,as this will acilitate the design o appropriate approaches or involving them. tis especially important to identi y supporters and opponents and, moreover, toappreciate the reasons or their respective positions so as to be able to develop amarketable package that satis es all parties concerned.

With these comments in mind, the key objectives o a stakeholder analysis are thus:to identi y key stakeholders, de ne their characteristics and examine how they will•

be a ected by the policy (e.g. their speci c interests, likely expectations in terms o bene ts, changes and adverse outcomes);to assess their potential in uence on the development, approval and•

implementation o a seat-belt programme;to understand the relationship between stakeholders and possible con icts o •

interest that may arise;to assess the capacity o di erent stakeholders to participate in developing a seat-•

belt programme and the likelihood o their contributing to the process;to decide how they should be involved in the process to ensure the best possible•

quality and viability o the programme, in particular:the nature o their participation (e.g. as advisers or consultants, or as▷

collaborating partners);the orm o their participation (e.g. as a member o the working group, or as an▷

advisor, or sponsor);the mode o their participation (e.g. as an individual participant or as a▷

representative o a group).

A more in-depth discussion on conducting a stakeholder analysis can be ound in Developing policies to prevent injuries and violence: guidelines or policy-makers and planners( ).




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What opposition might be expected in putting in place a seat-belt programme?

Anticipating opposition or constraints to establishing a seat-belt programme isuse ul to pre-empt these problems arising Opposition might arise due to:

competing priorities among policy-makers•

lack o nancial resources•

strong lobbying by groups opposed to increasing seat-belt use•

opposition to higher standards rom commercial interests•

2.3.3 Is there a seat-belt use law in place?

As already stated in this section, it is important to know what road sa ety laws existand whether they are adequately en orced. Experience has shown that road sa etylegislation without proper en orcement is unlikely to have the desired e ect. n part,this is because road users do not always recognize the risks involved and the bene tsto them o the protective measures contained in the legislation. For this reason, theydo not always support laws designed to improve their own sa ety on the roads.

A seat-belt programme may require the creation o a new law or the modi cation o an existing one. On the other hand, the existing law may be satis actory, but may notbe properly en orced. Most countries today have some type o law on seat-belt use. tis there ore use ul to begin by reviewing the current state o the laws, as shown in the

ollowing checklist: What current laws relate to road sa ety generally?•

s there a speci c law on seat-belt use? so, does it apply nationally or locally? s it•

up to date?o whom does the law apply – or example, to all drivers and passengers, and all•

age groups? Are there speci ed exemptions?Does the law apply to all types o road?•

Does the law speci y the type or standard o seat-belt or child restraint that should•

be worn? What are the penalties or not complying with the law?•

s the law en orced? s it en orced everywhere, and among all motor vehicle users?•

How is a new law o cially adopted by the government? What are the mechanisms•

o endorsement?




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The United Nations Economic Commission or Europe(UNECE) Working Party on Road Sa ety (WP1) carriedout a survey on seat-belt use and legislation or allits member countries and or a number o A ricancountries in 2005 The survey covered both adultseat-belts and child restraints, and it collected in or-mation on the ollowing topics:

collection o in ormation on seat-belt use•

legislation on the equipment o vehicles with•

seat-belts

legislation on seat-belt use•

exemptions rom mandatory use•

en orcement o seat-belt legislation•

education and campaigns•

evaluation and research on seat-belt wearing•

types o child restraints and legal requirements•

or their use

The questionnaire used in the survey is in Appendix1 and the results can be ound on the UNECE web-site ( 14 )

BOX 2 4:The UNECE survey o seat-belt use and legislation

The Organización Panamericana de la Salud or OPS(Pan American Health Association or PAHO) has pub-lished a review o sa ety legislation in Latin Americancountries that summarizes the legislation on seat-belt wearing

Car occupants

Compulsory seat-belt wearing or driver and ront•

seat passengers: Argentina, Chile, Colombia,Cuba, Dominican Republic, El Salvador, Mexico,Panama and UruguayCompulsory seat-belt wearing or all car occupants:•

Brazil, Costa Rica, Ecuador, Peru and Venezuela

Children

(a) Seating position

It is compulsory or children to travel in the rear seatso cars at the ollowing ages:

12 or younger: Argentina, Brazil, El Salvador and•

Uruguay10 or younger: Colombia and Venezuela•

8 or younger: Dominican Republic•

5 or younger: Mexico•

No legislation: Bolivia, Chile, Cuba, Ecuador, Guate-•

mala, Honduras, Panama, Paraguay and Peru

(b) Rules for child restraints

Costa Rica: Child restraints are compulsory or•

children that are 4 years o age or youngerEl Salvador: Child restraints are compulsory or•

children that are 2 years o age or younger with aweight not exceeding 15 kgBrazil: Children that are 12 years o age or younger•

and less than 1 5 metres (m) tall are to berestrained into a system according to their weightI no child restraint is available in the car, childrenyounger than 3 years o age should be restrainedby a seat-belt Children younger than 3 years o age must travel in a child restraint according to

their weight and heightColombia: Children that are 2 years o age or•

younger are to travel always in the back in achild restraint system that can be xed to thecar seat

In some cases the regulations are not national butregional, as in the case o Uruguay, or they apply tocertain types o vehicles, such as public transportbuses in Paraguay ( 15 )

BOX 2 5:Seat-belt and child restraint wearing legislation in LatinAmerican countries




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2.3.4 Is there a seat-belt and child restraint standard in place?

t is also very important to know whether the seat-belts and child restraints that areavailable meet approved standards. uch standards might be set by a national bodyor an international one (see Module ). Cars should be sold with evidence thatseat-belts are tted that meet such standards and there should be an active process o checking seat-belts or compliance with set standards. Tere should be a system orensuring that the child restraints available or purchase meet speci ed standards. Te

ollowing questions need to be asked:s there a national or international standard speci ed that seat-belts and child•

restraints should meet?Do currently available seat-belts and child restraints meet the standard?•

Do vehicle manu acturers abide by this standard?•

Do motor vehicle users wear seat-belts that meet such a standard?•

Are these seat-belts suitable or local conditions o heat and humidity?•

What is the cost o child restraints that meet recommended standards?•

2.3.5 Have an seat-belt and child restraint programmes beenattempted so ar?

n most places where motor vehicle use is high or increasing, some measures havealready been taken to increase the level o seat-belt use among motor vehicle users.Many countries have mandatory seat-belt laws and public awareness campaigns that promote seat-belt use. e ore launching a new programme it is important to be awareo these programmes, laws and campaigns and examine whether they have beene ective and whether they could be improved. uch a review can reduce costs andcan suggest better ways to carry out uture interventions.

Te ollowing checklist may be use ul in nding out about what has already beenimplemented:

Are there any other seat-belt or child restraint programmes currently in place in•

the country, or a neighbouring country? Who are the stakeholders o these programmes?•

Are there seat-belt use or child restraint programmes that have been conducted in•

the recent past? What were the outcomes o these programmes? Are the results available?•

What were the obstacles or constraints to these programmes? What lessons can be•

learnt?

able . summarizes the actions that may be taken to assess the current situationconcerning seat-belt and child restraint usage.




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Table 2.2 Summary o actions or assessing the current situation concerning

seat-belt and child restraint usage

Monitoring measures Details

Analysis o casualty data Identi cation o the real problem acing the countryDetermine seat-belt and child restraint usage rates o road casualties Calculate the savings (humanitarianand economic) that can be made rom increased use

Assess existing manu acturing standardsand legislation

Determine the adequacy o any existing standardsand legislation designed to control the tting andmaintenance o seat-belts and child restraints invehicles

Identi y any gaps in standards or legislation

Assess existing wearing legislation Determine the adequacy o existing legislation

designed to en orce the use o seat-belts and childrestraints

Identi y any gaps in legislation

Capacity to regularly test and monitor thecondition o seat-belts

Assess the capacity to undertake annual statutoryvehicle tests that include checks on the condition o seat-belts

Observed wearing rates

To highlight the percentage o vehicleoccupants wearing seat-belts and childrestraints at a national or state level

A sample survey orm can be ound inAppendix 2

A visual assessment o wearing rates, representingall types o road

Conducted at regular intervals – recommended every6 months

Using the same sites in selected areas o thecountry/state or each assessment

Weekend and weekday assessments

Observers need to indicate sex, seating position,approximate age, type o vehicle, i child restraintsand seat-belts are installed, and i they are being worn

Stakeholder analysis/market research Surveys indicating road vehicle occupants’ level o awareness and knowledge o seat-belts and childrestraints and their bene ts

Assessment o casualty statistics

Determine reasons or non-use

Child restraint sales

To indicate any increase in the purchase o child restraints

Number o child restraints sold by type

Vehicles sales

To establish the percentage o vehicles in usethat have seat-belts installed

Number o vehicles imported with or without seat-belts installed

Sales o new vehicles with seat-belts installed – maybe a ected by legislation

Convictions

To be used post-legislation, to indicate levelso e ective en orcement

Analysis o criminal statistics relating to vehicleoccupants in court or non-compliance with seat-beltlegislation




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2.3.6 Using the situational assessment to prioritize actions

Once the situation has been assessed, the process o prioritizing actions can begin. nmany countries, injury prevention and road sa ety are not recognized as major healthand development issues that require political backing. As a result, in these places, anetwork o key groups with a common interest in road sa ety needs to be created inorder to develop programmes to increase the use o seat-belts and child restraints.Research has shown that when many groups are involved in improving road sa ety,and success ully share the responsibilities, the e ects are much greater ( , ). Whatactions to take will depend on where the country is in relation to restraint awareness,campaigns and legislation. Once this has been determined using the in ormationobtained, as explained in this module, and using the summary o actions in able . ,

stakeholders will be in a position to identi y what is required.A big actor in prioritizing these actions will be the unds and resources available todeliver and support the actions undertaken. For example, in some countries nationaltelevision and radio is owned by the government and there ore advertising can beinexpensive. However, in countries where television and radio is not governmentowned, advertising can be a signi cant drain on the resources available.

However, educating the public is imperative at the outset o any new promotion,service or product, and seat-belts and child restraints are no exception. Vehicleoccupants need in orming and then re-educating to generate acceptance o the bene tso wearing a seat-belt. Continuous education is also necessary or uture generations.

Summary

e ore designing and implementing a seat-belt or child restraint use programme, asituational assessment must be conducted. Asking a number o the questions listedin this module can help identi y the particular problems around seat-belt use in the

country, make a strong argument in support o the programme and provide indicatorsthat can later be used to judge a programme’s success. Te extent o the problemo non-use o restraints needs to be assessed. Tis involves collecting data on roadcrashes and injuries, as well as on restraint wearing rates and reasons or non-use. Tisin ormation can be used as baseline in ormation and to identi y the main needs o the programme. ome o this in ormation may also be used in an evaluation o the project.

An analysis o what is already in place with regard to seat-belt and child restraint useneeds to be conducted. Tis involves examining who is in charge o road sa ety in thecountry or area, the nancial resources available or seat-belt use programmes, the legalinstruments already in place, whether a seat-belt standard is speci ed and what other

programmes are in place already or have been conducted in the region or country.




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Re erences

1. Improving car sa ety through accident research.Co-operative Crash njury tudy web site (http:// www.ukccis.org, accessed ovember ).

2. roughton J, Walter L.rends in atal car accidents: analyses o CCIS data. ransport ResearchLaboratory PPR , .

3. Holder Y et al., eds. Injury surveillance guidelines. Geneva, World Health Organization, (http://whqlibdoc.who.int/publications/ / .pd , accessed ovember ).

4. Malaysia burden o disease and injury study.Malaysia nstitute or Public Health, Ministry o Health, .

5. Statistical report: road accidents o Malaysia. Royal Malaysian Police, .6. Lewis J, Aguh . An assessment o seat belt compliance: be ore study.GR P Ghana Project Report,

.7. roughton J.Seat belt wearing rates in cars in England 19 2–2002.ransport Research Laboratory

Report RL , .8. Ressler WH. Why don’t more sraelis wear seat belts in the back seat? Public Health Review, ,

( ): – .9. Child car sa ety restraints research report.MR nternational Ltd, (http://www.df.gov.

uk/pgr/scienceresearch/otherresearch/think/childcarsa etyrestraintsrese ?page= #a ,accessed ovember ).

10. Mc lvenny et al. Rear seat belt use as an indicator o sa e road behaviour in a rapidly developing country. Journal o the Royal Society or the Promotion o Health, , ( ): – .

11. chopper D, Lormand JD, Waxweiler R, eds. Developing policies to prevent injuries and violence: guidelines or policy-makers and planners. Geneva, World Health Organization, .

12. National Highway ra c Sa ety Administration Buckle Up Campaign. Washington, DC, Unitedtates Department o ransportation, .

13. La Prévention Routière nternational (http://www.lapri.org, accessed ovember ).14. Synthesis o replies to the questionnaire on increasing the use o seat beltsandSynthesis o replies to the

questionnaire on child restraints. United ations Economic Commission or Europe, WP , Roadra c a ety.

15. Castiglione C, olis M, Concha-Eastman A. Lesiones no intencionales: legislacion de America Latina sobre programas preventives y responsabilidades.Organización Panamericana de la ud,

.

16. Lonero L et al. Road sa ety as a social construct.ransport Canada Report – – . Ottawa,orthport Associates, .17. ingvall C. Te zero vision. n: Van Holst H, ygren A, Tord R, eds. Proceedings o the frst

International Con erence: transportation, tra c sa ety and health: the new mobility. Gothenburg,Sweden, 1995. erlin, pringer-Verlag, – .



3How to plan and manage

a seat-belt programme



3.1 How to establish a working group 573 1 1 Who to involve? 3 1 2 Assigning roles to working group members 59

3.2 How to prepare and promote an action plan 613 2 1 Setting the programme’s objectives 613 2 2 Setting targets 3 2 3 Choosing per ormance indicators 633 2 4 Deciding on activities 643 2 5 Setting a time rame and phasing the programme 64

3 2 6 Estimating resource needs 693 2 7 Setting up a monitoring mechanism 723 2 8 Ensuring sustainability o the programme 73

Summary

Re erences




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Module 2 described how to assess the seat-belt situation in a country, whichis the rst stage in developing a seat-belt programme. Module describes

how to use the assessment in ormation to plan and manage a programme to increaseseat-belt use. Module gives detailed in ormation on how to design and implementindividual interventions.

Te two sections in this module cover:

3.1 How to establish a working group. Tis is an essential step to ensure overallcoordination o the programme with input rom all the main groups and individualsinvolved.

3.2 How to prepare a plan o action. ased on the assessment that was conducted

in Module , this section explains how to set objectives, de ne targets and decideon the activities to meet those targets. t also explains how to estimate a budget orthe plan and de ne a mechanism or monitoring and evaluation. Te section alsoaddresses the need to ensure the programme will be sustainable.

3.1 How to establish a working group

Having produced evidence that low seat-belt usage is a problem in the country orregion, it is crucial that representatives o the team make a strong case to politiciansand decision-makers to obtain their commitment and support.

Once there is su cient support, a working group o key stakeholders should beestablished, usually under the leadership o the country’s lead agency or road sa ety,or by a city or state government administration. ts goal will be to coordinate thedevelopment and delivery o a multisectoral programme to raise seat-belt wearing levels. Even i there is no clear lead agency or road sa ety it is important that onegovernment agency takes on board the responsibility or leading the seat-belt programme and that it has the capability to coordinate the work o all sectors involved.

Establishing an e ective working group is stage o the programme developmentand implementation process (see Figure . ) and this section gives guidance on whichstakeholders to engage and what roles should be adopted by the group.



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Module 3: How to plan and manage a seat-belt p rogramme

Figure 3.1 Stage 2: establishing a working group

Module 3

Appoint under capable lead agency or road sa ety•

Engage key stakeholders based on stakeholder analysis•

Win necessary support, coordinate the development and implementation o a national or local•

programme and action plan to implement it

3.1.1 Who to involve?

Te overall assessment o the country situation (Module ) includes steps on howto conduct a stakeholder analysis. Tis should indicate the best people to approach– rom within government bodies and other organizations – to participate in theseat-belt sa ety programme. n particular, it should identi y the main political guresto be involved and the best way to mobilize nancial support and communitybacking, as well as those with the relevant technical expertise.

Te working group should draw on the expertise and experiences o a range o individuals, including:

members o the lead agency;•

representatives rom relevant government agencies, such as those o transportation,•

health, police, education and law en orcement; public health and injury prevention specialists;•

health-care pro essionals;•

independent researchers;•

nongovernmental organizations, including those representing victims o road•

crashes;members o motoring organizations;•

seat-belt, child restraint and vehicle manu acturers;•

engineers and other specialists;•

large employers and managers o large car eets.•

Each o these partners has an interest in the outcome o the seat-belt programmeand each can help develop, implement and evaluate an action plan. Many o these partners will already be involved in road sa ety work and are there ore likely to beaware o at least some o the issues around seat-belts and their use.

deally, the working group should also include those who might be critical o a seat-belt programme. Teir position needs to be understood as well, so that a programmeis devised that addresses possible objections and is acceptable to the widest possiblesegment o society.




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o work well, a multisectoral working group should have well-de ned working procedures and a clear workplan, extending to the eventual implementation. t isimportant to have good communication within the group. o this end, there shouldbe someone within the working group responsible or disseminating in ormationamong the various members.

ecause o the di erent technical inputs required it may be best to set up anorganization with a management committee and subgroups ocusing on legislation,standards, en orcement and public in ormation, as illustrated in Figure . .

Figure 3.2 Example organizational structure o working group and possible tasks

Working group on seat-beltsManagement

committee

Monitor/evaluateprogress andimpact o pro-gramme againstobjectives

Subgroup 1

Legislation, standards,penalties

Subgroup 2

Mandatory measures

Subgroup 3

Voluntary measures

Discuss/ resolveproblems

Assess legislation

and proposechanges

Ensure good

cooperation withpolice

Assess public

knowledge

Ensure good com-munication among allworking group mem-bers and subgroups

Assess knowledge/compliance withlegislation

Assess, dra tstandards

Assess andstrengthen policepractice

Identi y pro es-sional needs, e gtraining, equipment

Develop/implementpublicity campaigns

Facilitate publiceducationand trainingprogrammes

3.1.2 Assigning roles to working group members

Certain unctions will be common to all well-organized seat-belt programmes.Tese include the initiation o the programme – its conceptualization and launch,the operation itsel , its coordination and the unction o advocacy. Tose who arespeci cally assigned to these unctions are described here because o their specialroles. ometimes, one person or agency may ul l more than one unction.



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Te initiator

Te person or agency initiating the activity does not need to be engaged in the waythat others who are involved are. However, the initiator must t into the operation toensure that the programme moves orward in a coordinated manner. Te enthusiasmo the initiator should be harnessed to the bene t o the programme.

Te operators

Te operators have the technical responsibility or carrying out various aspects o the programme. Frequently, they will be o cials o the lead and subsidiary agenciesinvolved, such as the department o transport, the ministry or department o legala airs and the police. Tey must be allowed to participate ully and their o cial workload adjusted accordingly. raining and other resources may also be required here.Operators need to be open to input rom others involved in the programme.

Te coordinator

Te coordinator has overall responsibility or the execution o the programme andtheir role is critical to its success. Te coordinator, whether paid or not, shouldhave clearly de ned responsibilities. Tese include overseeing the activities o the working groups, monitoring progress and ensuring that all those involved, including the initiator and operators, are kept well in ormed. Te coordinator should have

ull authority to carry out these unctions, as well as the resources and the supportneeded to implement these tasks. For this reason, the role is best lled by someone whose work already includes some o these responsibilities. uch a person may be thechie technical o cer within the transport department, the person in charge o thetra c police or a high-ranking o cial in the health ministry.

Te advocate(s)

Te advocate champions the cause o seat-belt and child restraint use. Tis is usuallyone person or several in uential people with good communications skills who are well known and respected. Te advocate and coordinator can have several qualitiesand tasks in common, and in some instances they are the same person. Prominent people who have themselves been a ected – generally adversely – by a lack o seat-belt use, or have had their lives saved by the use o a seat-belt, usually make goodadvocates.




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3.2 How to prepare and promote an action plan

e ore a comprehensive seat-belt programme can be implemented, a plan must be prepared showing what actions and resources are required to achieve the programmetargets. Tis plan must be backed up by data, as described in Module . An action plan can be prepared at a national, regional or even town level.

Developing the action plan is stage o the programme development process. Tekey steps involved are shown in Figure . and described in turn in the remainder o this section. A more in-depth discussion on developing an action plan or a national policy is ound in Developing policies to prevent injuries and violence: guidelines or

policy-makers and planners( ).

Figure 3.3 Stage 3: developing the programme and action plan

Module 3

Set objectives•

Set targets•

Set indicators•

Decide on activities•

Estimate resources•

Set time rame•

Set up monitoring/evaluation•

Use evaluation results as basis or creating next programme to ensure sustainability o increased•

wearing rates

3.2.1 Setting the programme’s objectives

Any seat-belt programme should contain speci c, measurable, achievable andrealistic objectives. Te objectives are developed by examining the data collected inthe situational assessment. Tis in ormation must be analysed by the working groupto identi y the problems to be addressed in the programme. n particular the groupshould identi y the vehicle type that they will ocus on and determine which types o occupant they will target, or example ront seat, rear seat or children.

n considering appropriate solutions to the problems, the working group shouldollow a systems approach; that is, one that considers the system as a whole and

identi es where there is potential or intervention ( ). olutions are thus likely toinclude measures that address the user, such as education, as well as en orcemento laws and regulations, design, standards and tment o seat-belts, all o which arecombined over a period o time.



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Te objectives will, in general terms, be one or more o the ollowing:to increase knowledge and awareness o road tra c sa ety, and seat-belt use in•

particular;to ensure that all new motor vehicles have seat-belts tted as standard;•

to increase the rate o seat-belt use;•

to improve the quality o seat-belts tted;•

to decrease the rate o serious injuries and deaths resulting rom vehicle crashes,•

particularly or vehicle occupants.

Malaysia has included increasing rear seat-beltwearing rates or car passengers in its 2006–2010National Road Sa ety Plan The programme startedin 2007 with advocacy and in orming the publicabout the importance o wearing rear seat-beltsThis was ollowed by a major multimedia publicitycampaign commencing in June 2008 and running

or six months En orcement will begin on 1 January2009 Indicators o expected progress, includingestimates o coverage and atality reduction, havebeen produced by the Malaysian Institute o RoadSa ety and are shown below They will be monitoreduntil the end o 2010

CASE STUDY: Example o a seat-belt programme target, Malaysia

Programme % intervention coveragePotentialreduction

No. o deaths

Expected no.o atalit reduction

2007 2008 2009 2010 % Involved/yr 2007 2008 2009 2010

Rear seat-belts 20 40 60 80 30 350 21 42 63 84

3.2.2 Setting targets

Once identi ed, such general objectives should then be made more speci c so thatthe programme has a clear results ocus. Te objective to increase the rate o seat-beltuse, or instance, might be stated as “increasing the rate o seat-belt use by a speci edamount, over a given time period”. t is generally pre erable to set measurable, time-limited objectives; these can be expressed in terms o atarget , or example percentagereduction (or improvement) to be achieved by a certain date, as illustrated in the casestudy rom Malaysia (see case study).

Having targets generally results in more realistic road sa ety programmes, a betteruse o public unds and other resources, and greater credibility o those operating the programmes (3, ).

Developing targets will require the use o crash and injury and other related baselinedata in order to establishmeasurable objectives. For example, an activity might aimto achieve a % increase in seat-belt use over a speci ed time period. Te experienceo other initiatives in road sa ety suggests that targets should be both ambitious




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and carried out over a long time period (). A longer time rame also allows or programmes to be introduced step by step.

etting targets or the rst time will be more di cult as no previous trend exists ormodelling the uture. However, much can be learned rom the experience o othercountries and evaluation studies.

able . provides some examples o objectives and possible targets. Precise changesand timescales are not speci ed but would normally be required.

Table 3.1 Examples o objectives and possible targets or a seat-belt programme

Programme objective Example per ormance targetsIncrease in driver andpassenger knowledge/awareness about seat-beltwearing

% increase in knowledge about the law and the penalties•

% increase in knowledge about the bene ts o using seat-belts•

% increase in awareness o increased en orcement by the police•

Increase tting o standarddriver and passenger seat-belts

National seat-belt standard/regulation approved ( or cars, trucks and•

buses)% increase in number o vehicles tted with standard seat-belts ( ront•

and rear, trucks and buses)

Increase wearing levels o seat-belts

Legislation on wearing and penalties enacted•

% increase in seat-belt wearing ( ront and rear, child, trucks and•

buses)% decrease in cases registered or seat-belt violations (only a ter•

en orcement has already made signi cant impact)Reduce atalities o driversand passengers o motorvehicles

% reduction in car driver atalities•

% reduction in atalities o ront seat occupants o cars•

% reduction in atalities o rear seat passengers in cars•

% reduction in atalities o child passengers•

% reduction in truck driver atalities•

% reduction in atalities o unrestrained vehicle occupants•

3.2.3 Choosing per ormance indicatorsTe previous section explained the importance o setting measurable targets. Tissection illustrates that there are a number o per ormance indicators that can beused both or providing a basis or targets and or measuring the progress o the programme.

ypical outcome per ormance indicators or seat-belt programmes are:the percentage o vehicles with seat-belts tted•

the extent o seat-belt awareness•

the extent o seat-belt use compliance•

the number o vehicle occupants injured or killed.•



64


Tese can be more detailed to meet the speci cations o the programme, orexample:

the seat-belt wearing rate, distinguishing between drivers and passengers and•

ront or rear seating positions ( or example, as a proportion o the total number o vehicle occupants in each category);a reduction in tting violations or seat-belts, using data rom inspectors’ reports.•

Te per ormance indicators can also include a wider range o intermediate outcomes,such as the extent o police en orcement o seat-belt laws as measured by the numbero police tickets issued.

Per ormance indicators can also relate to the project outputs, or example:the requency o public awareness campaigns•

the number o police trained in seat-belt en orcement•

the number o organizations adopting seat-belt rules or employees.•

When choosing per ormance indicators it is important to select those that bestmeasure the objectives. Ofen this will mean an extra e ort in collecting data andthis must be built into the programme. n order to show changes and improvementsresulting rom the programme, these data will need to be compared to baseline dataand take into account other actors that could have an impact on the programmeobjectives. For injury and mortality data it is important that the measure is ocusedon the target group o occupants and that comparisons with overall trends are made.

For each indicator there should usually be a speci c quanti able target, thoughoutput indicators may relate simply to completion o a key activity, or examplelegislation passed by a speci c date (see able . ).

3.2.4 Deciding on activities

Afer speci ying the objectives, targets and indicators, the working group mustdecide on and plan activities. able . presents a summary o a number o elementsthat could be included in a seat-belt programme. o help planners prioritize the keyactivities the table provides simple indications o their relative e ectiveness, ease o

implementation, cost and whether there is research to demonstrate the e ectivenesso the interventions. n ormation is also provided on the relevant sections in themanual (mostly Module ) where there is more detailed in ormation on how todesign and implement these components.

3.2.5 Setting a time rame and phasing the programme

An action programme to promote seat-belt use will include both preparatory steps,involving legislation, standards and design; and launching steps, which ensurecompliance with the laws and regulations through incentives and en orcement. Te

timing o each step should be considered when planning the project.




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P o s s

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t i n g a s e a

t - b e

l t p r o

g r a m m e

E l e m e n

t

D e s c r i p t

i o n

R e s e a r c

h

E e c

t i v e n e s s

D i f c u

l t y t o

u n

d e r t a

k e

C o s t

t o

i m p

l e m e n

t

S e c

t i o n

i n

t h i s m a n u a

l

H i g h p r i o r i t y

R o a

d s a e

t y / c r a s h

d a t a a s s e s s m e n

t

A s i t u a t i o n a

l o r n e e d s a s s e s s m e n

t i s c r u c i a

l o r

p l a n n

i n g t h e p r o g r a m m e a n d

o r c o n v i n c i n g

d e c i s

i o n -

m a k e r s o

t h e n e e

d o r a c t i o n a n

d r e s o u r c e s

Y e s

H i g h

L o w

L o w

2 1 ,

2 2 , 2

3

L a w s o n s e a

t - b e l t s

a n d c h

i l d r e s t r a

i n t s

T h e o v e r a

l l o

b j e c t i v e o

s e a

t - b e

l t l a w s

i s t o m a

k e s e a

t -

b e l t u s e u n i v e r s a

l I n t h e c a s e o s e a

t - b e l t s ,

l e g i s

l a t i o n

n e e

d s

t o d e a

l w i t h :

S e a

t - b e

l t t t i n g

b y v e

h i c l e t y p e a n d

i n s p e c t i o n ;

•

S e a

t - b e

l t w e a r i n g

b y v e

h i c l e t y p e ,

p a s s e n g e r l o c a

t i o n ,

•

c h i l d r e n ;

P e n a l t

i e s

o r n o n - c o m

p l i a n c e

( m u s t

b e s e r i o u s

•

e n o u g h

t o d e

t e r n o n - c o m

p l i a n c e

)

Y e s

H i g h

w h e n

b a c k e

d

u p

b y s t r o n g

e n

o r c e m e n

t

L o w

i t h e r e

i s

p o

l i t i c a l

c o m m

i t m e n

t

L o w

4 2

S t a n

d a r d s

o r s e a t -

b e l t e q u

i p m e n t a n

d

t t i n g

A s e v i d e n c e s h o w s

t h a t h a

l o r m o r e o

v e h

i c l e s

i n l o w -

i n c o m e c o u n

t r i e s m a y

l a c k p r o p e r

u n c t i o n

i n g s e a

t - b e l t s

( 6 ) , i t i s v i t a

l t h a t p r o p e r s t a n d a r d s a r e e s t a

b l i s h e

d o r

s e a

t - b e l t s a n d

t h e w a y

t h e y a r e

t t e d

Y e s

o r

i m p r o v e

d

s p e c i c a

t i o n s

H i g h

i c o m p l i a n c e

m o n i t o r e

d

L o w

L o w

4 3

S t r o n g e n

o r c e m e n

t

o s e a

t - b e l t l a w s

T h e m o s

t e e c t i v e e n

o r c e m e n t

i s a s t r o n g , v i s i b

l e a n

d

i n t e l l i g e n c e - l e

d a p p r o a c h a

t l o c a t i o n s a n d

t i m e s

t h a t

m a x i m

i z e

d e s i r e

d i m p a c t a n d m e e

t s a

e t y r e q u i r e m e n

t s

o r s t o p p

i n g v e

h i c l e s

I n t e n s i v e e n

o r c e m e n

t

p r o g r a m m

e s s h o u

l d b e p r e c e d e

d b y p u

b l i c i t y a n d

i n o r m a t

i o n c a m p a

i g n s , p o s s i b

l y w

i t h a w a r n

i n g p

h a s e

b e

o r e p r o s e c u

t i o n s s t a r t

P e n a

l t i e s

s h o u

l d b e a p p

l i e d s w

i t l y a n d c o n s i s

t e n t l y

w i t h o u t d

i s c r e t i o n a n

d c a n

b e i n c l u

d e d

i n a p e n a

l t y

p o

i n t s s y s t e m

Y e s

H i g h

L o w

n e e

d s

r e a s o n a b

l e

p u b l i c s u p p o r t

a t t h e o u

t s e

t

M e d i u m

4 4

P u

b l i c i t y c a m p a i g n s

P u b

l i c i t y i s a c r u c i a

l c o m p o n e n

t o r p r e p a r i n g

t h e

p u

b l i c

o r e n

o r c e m e n

t c a m p a

i g n s , e s p e c i a

l l y o r n e w s e a

t - b e l t

l a w s

O n t h e i r o w n ,

p u

b l i c i t y c a m p a

i g n s w

i l l h a v e a

l i m i t e d i m

p a c t o n s e a

t - b e

l t u s a g e a n

d t h e y s h o u l

d b e

s u p p o r t e

d b y a n e

e c t i v e e n

o r c e m e n

t s t r a t e g y

Y e s

H i g h

i n c o m

b i n a

t i o n

w i t h

l e g i s

l a t i o n a n d

e n

o r c e m e n t

M e d i u m

H i g h

4 6

C o n

t i n u e

d . . .




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Te sequence o actions is important; some key recommendations are shown inox . .

Start with legislation on seat-belt tting be ore1seat-belt wearing

Start the process o adopting seat-belt standards2(regulations) as soon as possible but do not let ithold up the legislation process

Always in orm the public about new legislation or3

en orcement practice be ore changing en orce-ment practice

Try to combine in ormation and publicity activities4with en orcement, as an integrated approach ismuch more e ective than either o these activitiesin isolation

Consider a phased approach in the long-term5programme, e g start with cars, then buses andtrucks

BOX 3 1:Sequence o actions in a seat-belt programme

Phasing should also be considered in the long-term programme. Tis particularlyrelates to legislation when countries may wish to tackle ront occupants o cars be orerear seat occupants, and be ore child restraints, ollowed by bus and truck occupants.Phasing o legislation is dealt with in more detail in section . . .

Te time rame will depend on activities agreed upon. For example, i legislation isto be developed and implemented, a decision may be taken to phase in en orcemento the new law gradually in di erent areas (see section . . ). However, clearly anoverall timeline must be agreed upon at an early stage in the planning process, as thismay be a ected by the availability o resources.



68


C A S E S T U D Y :

E x a m p

l e s e a

t - b e

l t c a m p a

i g n s c

h e

d u

l e ( e n f o r c e m e n

t + p u

b l i c i t y ) , S a

k h a

l i n I s l a n

d , R

u s s

i a

W o r k p a c k a g e

M a r c h

A p r i l

M a y

J u n e

J u l y

A u g u s t

S e p t e m b e r

O c t o b e r

N o v e m

b e r

O f c i a l l a u n c h o

c a m p a

i g n

x

1 .

P l a n n

i n g a n

d p r o

d u c

t i o n o

m a

t e r i a

l s

C a m p a

i g n p

l a n n

i n g

R a

d i o s p o

t p r o

d u c t i o n

D e s

i g n o

n e w a w a r e n e s s m a

t e r i a

l s

A p p r o v a

l p r o c e s s

P r o

d u c t i o n o

a w a r e n e s s m a

t e r i a

l s

P r o

d u c t i o n o

b i l l b o a r d s

2 .

M a s s m e

d i a c o m m u n

i c a

t i o n s p r o g r a m m e

T V b r o a

d c a s t i n g

R a

d i o m e s s a g e s

P r e s s a

d v e r t s

B u s a

d v e r t s

B i l l b o a r d s

T V r e p o r t s a

b o u

t p r e - l a

u n c h s e m

i n a r s

P o s

t e r s

i n t r a

d i n g c e n

t r e s

3 .

P u

b l i c r e

l a t i o n s a n

d c o m m u n

i c a

t i o n s a c

t i v i t i e s

D i s t r i b u

t i o n o

c a m p a

i g n m a

t e r i a

l s

S e m

i n a r s

i n u n

i v e r s

i t i e s

S e m

i n a r s

i n G I B D D

a o

c e s

S e m

i n a r s

i n s c h o o

l s

L a u n c h e v e n

t i n K o r s a

k o v

L a u n c h e v e n

t i n K h o

l m s

k

L a u n c h e v e n

t i n N o g l i k i

G I B D D a n

d m a s s m e

d i a b r i e

n g

4 .

E n

o r c e m e n

t

A c t i v e

G I B D D e n

o r c e m e n

t

5 .

M e a s u r e m e n

t

T h r e e p

h a s e s o

v i d e o m o n

i t o r i n g

P o s

t - c a m p a

i g n s u r v e y

a

G I B D D :

S t a t e I n s p e c t o r a

t e o r

T r a

c S a e

t y




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3.2.6 Estimating resource needs

Tere will be an inevitable need or initial and sustained investment in order toensure a coordinated approach to increasing seat-belt usage. Costs will be incurredthroughout the design o legislation, including the consultation process.

As part o designing the programme, it is there ore important that the ollowing steps are taken:

Te human resource needs, including training, should be estimated.•

Te costs o implementing the programme must be broken down by component•

and by activity chosen.ational and international unding sources must be identi ed. deally, ministries•

who will be involved in implementing the programme should adjust their budgetsto re ect the new activities. Alternatively, the working group can try to secure

nancial support rom donors.

Failure to ully address resource needs or implementation during the planning stagecan jeopardize the uture success o the programme. Tus it is important that the working group is realistic in estimating the likelihood o securing the unding needso the programme.

Having planned the programme activities in detail, the working group can nowestimate the cost o each activity and in the process draw up a budget, based onquotes rom suppliers or on the cost o recent similar undertakings.

When ormulating budgets, the ollowing actions are recommended:estimate the unds available or the duration o the project;•

set priorities, with activities phased i necessary to ensure that priority activities•

receive adequate unding;discuss, with other government departments, non-pro t-making organizations and•

private sector rms, similar projects already undertaken and their costs;estimate the likely administrative and operational expenses in implementing the•

programme;estimate the cost o monitoring and evaluation;•

plan or nancial reports at regular intervals.•

t is essential that the government has ownership o the programme and nances it.able . provides an example o a seat-belt campaign budget. able . and the case

study rom Fiji on road sa ety levies provide some suggestions on how to nance aseat-belt campaign.



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Table 3.3 Example seat-belt campaign budget (US$, VAT inclusive)

Seat-belt publicity campaign budget breakdown or a group o smaller cities (400 000 population)or 2005

No. Item Jul Aug Sept Oct Nov 20 Dec a Total

1 Mass media b

1 1 TV broadcasting 5 000 4 700 4 900 14 600

1 2 Radio 2 000 2 000 2 000 6 000

1 3 Printed media, newsagencies, Internet

3 500 5 400 5 200 5 500 19 600

2 Public relations activities and educational campaign

2 1 Educational campaign 14 000 9 000 23 000

2 2 Public relations activities 5 500 2 500 500 8 500

3 Advertisements and printing production

3 1 Production o advertisingmaterials

2 250 5 250 2 800 2 000 1 500 500 14 300

3 2 Outdoor advertising 4 000 6 950 5 950 700 17 600

4 Analytical, organizational,creative work

6 300 9 600 9 350 5 800 3 800 3 300 38 150

5 Total as per block 12 050 14 850 16 150 46 650 34 650 17 400 141 750

6 Agency fee 21 250

7 Technical expenses c 9 250

8 Incidental expenses, unanticipated needs 7 750

Total 180 000

a Preliminary date

b Broadcasting in ormation messages in news blocks and interviews are presumed to entail no cost

c Includes, or example, hotel, o ce ( our work positions), o ce equipment, transport, cellphones, per diem allowance, air travel




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Table 3.4 Possible ways to und a seat-belt wearing campaign

Source o unding Method o unding

Reinvestment Some o the money rom nes or non-compliance can be reinvested ina central und to support public education and to help train the policeto en orce the law Similarly, unds rom uel tax, vehicle licence andregistration ees can be earmarked or particular purposes related tothe seat-belt programme A road sa ety levy could be incorporated intoinsurance premiums and allocated to the central collision prevention undI used, the World Bank recommends a tari equivalent to 8% o premiums

Sponsorship Corporate groups o ten sponsor activities they see as wor thwhile, and theymay und a seat-belt programme or speci c components o it Companiesinvolved in manu acturing vehicles, or those selling insurance, maybene t by being seen as major sponsors o a seat-belt wearing campaignStakeholders should explore whether there could be any legitimate tie with

vehicle or seat-belt manu acturers This may produce ur ther sponsorshipor related campaigns, but may also allow the opportunity or discounts soowners, particularly those in less a fuent social groups, can a ord to tseat-belts to un tted older vehicles

Donor organizations Development aid agencies and other charitable organizations are possiblesources or unding a seat-belt programme In a similar way, road sa etyorganizations and educational bodies may provide unding or contributetechnical expertise

Voluntary nancial donations are given every quarterby the motor insurance industry in Fiji These amountto approximately 10% o third-party premiums andare dependent on the number o new policies Thisprovides the National Road Sa ety Council with 60%o its unding

The Transport Accident Commission (Victoria,Australia) provides unding or road sa ety throughboth a mandatory levy and a voluntary levy Dona-tions started at 3% but have risen to 10% This

unding or road crash reduction and rehabilitationprogrammes reduced road deaths by 50% in lessthan our years ( 7 )

South A rica employs a system whereby third-partyinjury insurance is collected through a uel levy There-

ore, each time a vehicle owner or driver purchasesuel or uses their vehicle, they also purchase third-

party injury insurance As a result, non-complianceis virtually non-existent ( 7 )

CASE STUDY: Examples o road sa ety levies



72


Who pays? Investing in seat-belt programmes

Governments and policy-makers must realize that a seat-belt programmerequires considerable investment, but that there can be signi cant economicreturns on investment and overall societal bene ts through reduced medicalcosts Cost–bene t analyses that quantitatively illustrate that nancing a seat-belt programme provides value or money may be very use ul in gaining politicalsupport or a seat-belt initiative I such studies have not been conducted in acountry, it may be necessary to rely on data or examples rom similar countries,and to incorporate a cost–bene t analysis into the evaluation o the plannedseat-belt programme (see Module 4)

3.2.7 Setting up a monitoring mechanism

Monitoring the programme involves keeping a close check on all measurementindicators to ensure the programme is on track towards the goals set out. Evaluationmethods are discussed in more detail in Module .

Monitoring can be:

continuous•

, with the lead agency o the working group overseeing the overall programme in case problems arise; periodic• , with activities measured at the end o each stage o implementation.

able . gives an example o what might be monitored during a typical seat-belt wearing programme, and the possible actions to take i the indicators suggest thatactivities are missing their objectives. t is important to:

de ne resources or this task: human as well as nancial resources should be•

allocated at the outset o the process to ensure that the monitoring and evaluationtakes place at an appropriate time and the results are disseminated;de ne the mechanism or monitoring: setting out who will be responsible or•

monitoring progress, at what intervals progress should be reported and to whom,and how implementation can be en orced i needed, as early as possible; put in place a eedback mechanism to allow the regular revision o a programme,•

should it be necessary to improve its accuracy and relevance.




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Table 3.5 Monitoring indicators and corrective action

Activit Indicator(s) or monitoring Actions to take i monitoringsuggests activit is below target

Improvingmanu acturers &dealers compliancewith seat-beltstandards

Number o trained inspectors•

Number o tests conducted•

Number/% o ailure reports•

Improve in ormation about•

standards

Increase number o trained•

inspectors

Increasing capacity opolice to en orce

Seat-belt wearing rates•

Amount o en orcement activity and•

extent o area covered by en orcement

Number/amount o tickets/ nes issued•

Increase size o tra c police•

orce and raise priority given toseat-belt checks

Change en orcement areas and•

techniques

Improve system o issuing•

tickets and collecting nes

Implementingawareness campaignon road sa ety andseat-belt use

Level o awareness o tra c sa ety•

Level o awareness o bene ts o seat-•

belt use

Level o knowledge o seat-belt laws and•

their en orcement

Observed (or sel -reported) changes in•

behaviour

Rede ne target audience•

Rede ne message(s)•

Evaluate the means o •

delivering the messages andchange them i necessary

3.2.8 Ensuring sustainabilit o the programme

Te sustainability o a seat-belt programme is essential to ensure that bene ts thatresult rom the programme persist. Even when compliance has been raised to highlevels there are likely to be certain sections o the population who remain resistantto wearing seat-belts. ew generations o drivers need to be made aware o the riskso not wearing a seat-belt. argeted publicity campaigns as well as sustained levels o en orcement will be needed to ensure that seat-belt wearing rates do not decline.

uccess ully sustaining a programme also requires that the components o the programme are evaluated to determine what worked and what did not work (seeModule ). Te results o this evaluation should be ed back into the design andimplementation o uture activities.

t is also important that successes are recognized by congratulating the teamsinvolved and by giving them widespread coverage in the media.



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Summary

A working group should be set up to oversee the ormation o a seat-belt use programme. Consisting o individuals rom a range o relevant backgrounds anddisciplines, this working group will advise on all matters o the programme andensure the necessary coordination between its di erent activities. Te group shouldhave the authority to carry out the programme.

Once a working group is established, the results o the situational analysis can beused to plan the programme. Activities can then be de ned in the areas o legislation,en orcement and education. Alongside each activity, programme goals and objectives

should be set.Funding needs to be secured or the programme so that it can be e ectivelyimplemented. Monitoring the programme throughout its various stages is essential,to identi y shortcomings and correct them. Finally, an outcome evaluation should becarried out to determine whether the programme has been e ective. ased on this,

uture programmes can be built, sustaining the impact o the initial programme.

able . summarizes the main steps in planning and managing a seat-belt programme.

Table 3.6 Main steps in planning and managing a seat-belt programme

Activit Steps in planning and managing a seat-belt programme

Establishing a working group Ensure all those with an interest are represented•

Assign roles to members•

Promote and ensure commitment rom senior stakeholders•

Developing an action plan De ne objectives•

Set targets•

Select activities needed to achieve objectives•

De ne per ormance indicators or activities•

Estimate resources required•

Articulate how the programme will be monitored and evaluated•

Ensuring sustainability o theseat-belt programme

Plan or a minimum ve-year time rame and even longer-term•

unding to ensure sustainability o the programme

Use monitoring and evaluation results as the basis or enhancing•

e orts and planning the next round o activities




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Re erences

1. chopper D, Lormand JD, Waxweiler R, eds. Developing policies to prevent injuries and violence: guidelines or policy-makers and planners. Geneva, World Health Organization, .

2. Peden M et al.World report on road tra c injury prevention.Geneva, World Health Organization,.

3. argeted road sa ety programmes.Paris, Organisation or Economic Co-operation andDevelopment, .

4. Elvik R. Quanti ed road sa ety targets: a use ul tool or policy making? Accident Analysis and Prevention, , : – .

5. Elvik R. Quantifed road sa ety targets: an assessment o evaluation methodology. Report . Oslo,nstitute o ransport Economics, .

6. Primary en orcement saves lives: the case or upgrading secondary sa ety belt laws. ational Highwayra c a ety Administration, (http://www.nhtsa.dot.gov/people/injury/en orce/

PrimaryEn orcement/index.htm, accessed April ).7. Aeron-Tomas A.Te role o the motor insurance industry in preventing and compensating road

casualties. Crowthorne, United Kingdom, RL Ltd, .



76



4How to develop and

implement interventions



4.1 Increasing usage: the combined approach 8 1

4.2 Legislation and penalties 82

4 2 1 Developing seat-belt ftting and usage laws 834 2 2 Identi ying legal responsibilities 864 2 3 Exemptions 864 2 4 Penalties or non-compliance 874 2 5 Developing and implementing legislation 894 2 6 Phasing implementation 914 2 7 Section summary: checklist or seat-belt legislation 92

4.3 Seat-belt standards and equipment 934 3 1 Adopting a standard or regulation 944 3 2 Types o standards or regulations and their content 974 3 3 Testing and certifcation 984 3 4 Vehicle inspection and seat-belt maintenance 994 3 5 Retrospective ftting 1004 3 6 In-vehicle reminder systems 1024 3 7 Section summary: checklist or developing

seat-belt standard or regulation 103

4.4 Increasing usage: en orcement 1044 4 1 Pre-requirements 1044 4 2 En orcement strategy 1054 4 3 En orcement methods 1084 4 4 Police training 1094 4 5 Processing penalties 1094 4 6 Overcoming obstacles to en orcement 110

4 4 7 Section summary: increasing seat-belt usagethrough en orcement

4.5 Increasing usage: voluntary measures 1 1 2

4.6 Increasing usage: publicity campaigns 1 1 34 6 1 Objectives o the campaign 4 6 2 Creating campaign messages 4 6 3 Reaching the target audience 4 6 4 Creative concepts 4 6 5 Selecting an agency or the campaign 122

4 6 6 Working with the media 4 6 7 Campaign stages in relation to seat-belt

legislation 4 6 8 Evaluating the campaign

4.7 Increasing usage: other voluntary measures 127

4 7 1 Employer regulation and incentive schemes 1274 7 2 Education and training 4 7 3 Insurance and public incentive schemes 132

4.8 How to ensure an appropriate post-crash

response4 8 1 Seat-belts and injuries 4 8 2 Seat-belt removal

Summary

Re erences




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Module 3 provided in ormation on stage , how to develop the programmeand action plan. t included advice on choosing priority actions and a

summary o high- and medium-priority interventions together with an indication o their relative e ectiveness, ease o implementation and cost (see able . ).

Module moves onto stage (see gure . ) and gives guidance on how to developand implement each key activity o a programme aimed at increasing seat-belt usage.

Figure 4.1 Stage 4: develop and implement individual activities

Stage 4

Legislation and penalties•

Standards and equipment•

En orcement•

Publicity campaigns•

Voluntary approaches•

Post-crash response•

Te module stresses the need or an integrated approach combining measures that work well together. t also provides substantial in ormation on each activity and thestructure o this activity, as shown in able . .

Whilst this module gives advice on interventions in respect o seat-belts, it is alsoapplicable to programmes aimed at increasing the use o child restraints. Where thereare issues that are speci c to child restraints these are also included, but in general, toavoid repetition, re erence is made to seat-belts only.



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Module 4: How to develop and implement interventions

Table 4.1 A summary o key areas o activity and interventions to be included in

a seat-belt programme

Ke areas o activit Guidance provided on: Section

Legislation and penalties Developing tting and wearing laws•

Identi ying legal responsibilities•

Exemptions•

Penalties or non-compliance•

Introducing and implementing legislation•

Phasing implementation•

4 2

Standards and equipment Adopting a standard•

Types o standard•

Testing and certi cation•

Vehicle testing and seat-belt maintenance•

Retrospective tting•

In-vehicle reminder systems•

4 3

Increasing usage: en orcement Pre-requirements•

En orcement strategy•

En orcement methods•

Police training•

Processing penalties•

Obstacles to en orcement•

4 4

Increasing usage: voluntaryapproaches

Publicity campaigns, including:•

Objectives o the campaign–Creating campaign messages–

Reaching the target audience– Creative concepts–Selecting an agency or the campaign–Working with the media–Campaign stages in relation to seat-belt legislation–Carrying out and evaluating the campaign–

4 5, 4 6

Other voluntary approaches, including•

Employer regulation and incentive schemes–Education and training–Insurance and public incentive schemes–

4 7

Post-crash response Rescue and rst aid requirements• 4 8




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4.1 Increasing usage: the combined approach

Once seat-belts have been installed in a vehicle, the next objective is to ensure thatthe vehicle occupants use them.

mproving seat-belt and child restraint use calls or a combined approach involving a range o sectors and disciplines (see Figure . ). Te most power ul intervention isen orcement but to be e ective it needs to be implemented afer the public have beenin ormed about seat-belts and the law.

Education, training and publicity should be used to ensure that there is su cient public and political acceptance o the law and proposed en orcement. t should alsobe recognized that education and publicity without en orcement will only have alimited e ect; or example, publicity used in the United Kingdom between and

raised seat-belt wearing rates to %, but no higher (). Te most e ective roadsa ety programmes have been those that achieve a change in behaviour. t is o coursealso important to increase awareness and improve attitudes, but lives are actuallysaved when the desired behaviour patterns are adopted ( ).

Tere are also other voluntary measures, such as employer regulation and incentiveschemes and insurance and public incentive schemes, that can have an impact. Teseare not under the direct control o governments but they should be encouragedunder a partnership approach to road sa ety.

Adopting an integrated programme o interventions

Overall an integrated programme o interventions should be adopted, withmore emphasis being placed on voluntary methods at the start o multisectoralprogrammes ollowed by a progressive reliance on en orcement to reach highlevels o compliance



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Figure 4.2 The combined approach to increasing seat-belt usage

InterventionsLegislation, penalties, standards

The combined approach

Laws on ttings &usage

Mandatory Voluntary

Penalties & nes

Insurance & incentiveschemes

Publicity campaignsPolice en orcement

Standards &equipment

Employer regulation& promotion

Education & training

4.2 Legislation and penalties

Te overall objective o a law is to make seat-belt use universal. Tis can be achievedby targeted and appropriate legislation on seat-belt tting and wearing that isconsistently en orced and well understood by the public. All three components areneeded or success but clearly the rst task is to develop and implement appropriatelegislation.

Te process o developing a law, though, will also help with other activities, suchas the practical issues around en orcing the law. n addition, the process shouldstrengthen the public consensus on the need or a seat-belt law.




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In the case o seat-belts, legislation needs to deal with the ollowing three key issues:

seat-belt tting by vehicle type and inspection•

seat-belt wearing by vehicle type, passenger location, children•

penalties or non-compliance•

BOX 4 1:Key seat-belt legislation

4.2.1 Developing seat-belt ftting and usage laws

n most cases, seat-belt tting and wearing laws will involve adding a clause to a lawalready in existence, such as a road tra c or motor vehicle act. ometimes, though, acompletely new piece o legislation will be necessary.

Te assessment o the current legislative situation (Module ) will have identi edthe gaps and weakness in the system and the priority improvements required. Teseimprovements are likely to include:

drafing and enacting new legislation;•

expanding the scope o an existing law, or example to include additional vehicle•

occupant groups such as rear seat occupants;more clearly de ning the actions required under the existing law and those•

responsible;increasing the penalties or non-compliance;•

increasing en orcement powers.•

o help with the assessment process and with the development o legislation someexamples rom a number o countries o legislation on seat-belt tting, adult seat-belt use, and child restraint use have been provided in oxes . and . . Appendix provides an example seat-belt law.



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INDIA

Text:

33a/125: Sa ety belt collapsible steering column,autodipper and padded dash boards:

(1) One year rom the date o commencement o theCentral Motor Vehicles (Amendment) Rules, 1993,the manu acturer o every motor vehicle other thanmotor cycles and three-wheelers o engine capacitynot exceeding 500 cc shall equip every such vehicle

with a seat-belt or the driver and or the personoccupying the ront seat

34/1-A: The manu acturer o every motor vehicle o M-1 category shall equip every motor vehicle witha seat-belt or a person occupying the ront acingrear seat:

Provided that the speci ications o Sa ety BeltAssemblies and Sa ety Belt Anchorages in motorvehicles shall con orm to AIS 005–2000 and AIS

015–2000 speci cations, respectively, as may beamended rom time to time, till such time as corre-sponding Bureau o Indian Standards speci cationsare noti ed;

Provided urther that on and a ter 1st October,2002, the speci cation o Sa ety Belt Assembliesand Sa ety Belt Anchorages in motor vehicles shallcon orm to AIS 005–2000 and AIS 015–2000 speci-

cations, respectively

37/125-A: Sa ety belt, etc , or construction equip-ment vehicles:

One year rom the date o commencement o theCentral Motor Vehicles (Amendment) Rules, 2000,the manu acturer o every construction equipmentvehicle other than an agriculture tractor shall equipevery such vehicle with a seat-belt or the driver and

or the person occupying the ront seat, and with arear view mirror

KENyA

Text:

No motor vehicle shall be used or driven on a roadunless it is tted with seat-belts in the ollowingmanner:

(1) A seat-belt per seating position in a motor vehicle,and i seating accommodation is provided or morethan two persons abreast whether by a continuous

seat known as a “bench seat” or by separate seats,the seat-belts or the persons other than thoseseated next to the body o the vehicle may consistonly o a lap strap position o the seat

(2) The owner o any motor vehicles used or drivenon a road contrary to paragraph (1) shall be guiltyo an o ence and liable to a ne o one thousandshillings or every seat that is not tted or, i tted, isnot o the proper standard or speci cation

BOX 4 2:Example extracts o laws on seat-belt tting

Source: Central Motor Vehicles Rules, 1989, as amended byCentral Motor Vehicles (First Amendment) Rules, 2003

Source: Laws o Kenya: The Tra c Act, Chapter 403,Section 119, Rule 22A (1) – Seat-belts




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AUSTRALIA

Text:

Rule 264: Wearing o seatbelts by drivers

(1) The driver o a motor vehicle that is moving, oris stationary but not parked, must comply with thisrule i the driver’s seating position is tted with aseatbelt

(2) The driver must wear the seatbelt properlyadjusted and astened unless the driver is:

(a) reversing the vehicle; or

(b) exempt rom wearing a seatbelt under rule 267

Rule 265: Wearing o seatbelts by passengers 16years old, or older

(1) A passenger in or on a motor vehicle that is mov-ing, or is stationary but not parked, must comply withthis rule i the passenger is 16 years old, or older

(2) The passenger must occupy a seating positiontted with a seatbelt i :

(a) there is a seating position tted with a seatbeltthat is not already occupied by someone else who isnot exempt rom wearing a seatbelt; and

(b) the passenger is not exempt rom wearing aseatbelt under rule 267

(3) I the passenger occupies a seating positiontted with a seatbelt, the passenger must wear the

seatbelt properly adjusted and astened unless thepassenger is exempt rom wearing a seatbelt underrule 267

(4) I the motor vehicle has 2 or more rows o seats,the passenger must not sit in the ront row o seatsunless:

(a) the passenger is occupying a seating positiontted with a seatbelt; or

(b) there is not a seating position available or thepassenger in another row o seats; or

(c) the passenger is permitted to sit in the ront rowo seats under another law o this jurisdiction

KENyA

Text:

(3) No person shall be in a motor vehicle which is inmotion on a road and occupy a seat in a vehicle inrespect o which a seat-belt is tted in accordancewith this rule without wearing the seat-belt

(5) It shall be the responsibility o the conductor o apublic service vehicle, and where there is no conduc-tor, the driver o that vehicle, to keep the seat-belt ina clean, dry and generally wearable condition


VIET NAM

Text:

I motor vehicles are equipped with seat-belts, the driver and the occupant o the ront seat in the vehicleshall asten the seat-belts

BOX 4 3:Example extracts o laws on wearing seat-belts

Source: Australian Road Rules 1999; Part 16, Rules orpersons travelling in or on vehicles

Source: Article 9 – General provisions; Chapter II – Rules or road tra c; Road Tra c Sa ety Law No26/2001/QH10, passed by the National Assembly in Session 9, 10th Congress, 22 May to 29 June 2001



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4.2.2 Identi ing legal responsibilities

Legislation should clearly identi y who is responsible or complying with the law:For the tting o seat-belts this is usually the manu acturer and sometimes the•

vehicle owner (see ox . ).For children it is strongly recommended that the adult driver is made responsible•

or the appropriate restraining o all children within the vehicle.For public service vehicles it is usually adult passengers who are responsible. Te•

driver or the conductor can also be made responsible or keeping the seat-beltclean, as in the Kenyan example in ox . .

4.2.3 Exemptions

takeholders should consider justi cations or exemptions to the law and clearly state which vehicle occupants and under what circumstances may be exempt rom wearing a seat-belt. Tis area o legislation is complex and widespread exemptions under thelaw are not advisable as they could undermine the e ectiveness o a seat-belt use programme. Also, en orcement may be more time consuming and more di cult i there are di erences in where the law applies, or i there are people who are exempt

rom the law.

earing this caution in mind it may still be desirable to allow certain well-de nedexemptions (see ox . ), such as:

Emergency services.• On emergency response, or or other specialist reasons; thisshould not be a routine exemption, i.e. or every journey.

ypes o vehicle.• takeholders may wish to consider exemptions or driverso commercial passenger-carrying vehicles, such as taxis, i this is considered justi able.Health reasons.• Persons holding a valid certi cate signed by a medical practitioner to the e ect that it is inadvisable on medical grounds or them to weara seat-belt, e.g. ollowing major heart surgery. ote that pregnant women shouldnot be exempt rom the seat-belt law but they should only wear a three-point lapand diagonal seat-belt, not a lap belt on its own. Tey should also be given clearadvice on the sa e way to wear the seat-belt (Figure . ).




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UNITED KINGDOM

Text:

You must use a seat-belt in cars, vans and othergoods vehicles i one is tted Adults, and childrenaged 14 years and over, must use a seat-belt where

tted, when seated in minibuses, buses and coachesExemptions are allowed or the holders o medicalexemption certi cates and those making deliveriesor collections in goods vehicles when travelling lessthan 50 metres (approx 162 eet)

BOX 4 4:Example extract o law on exemptions

Source: Laws RTA 1988 sections 14 and 15, MV(WSB)R,MV(WSBCFS)R & MV(WSB)(A)R & (MV)(WSBCFS)(A)R

Figure 4.3 Three-point lap and diagonal seat-belts essential or pregnant mothers

“Mother and unborn childare both sa er in a collisioni a lap and diagonal seat-belt is worn correctly ”

Royal Society or thePrevention o Accidents

(RoSPA)

When considering exemptions it should not be orgotten that with the exception o a medical condition whereby the use o a seat-belt may urther endanger the li e o anindividual, seat-belts do save lives. Also, when making exemptions, legislation shouldensure that there are clear de nitions that prevent ambiguities.

4.2.4 Penalties or non-compliance

Clearly the penalty or non-compliance must be perceived as su ciently serious todeter would-be law-breakers. Te penalties should be set in line with penalties orother tra c law violations and they can be linked to a penalty points system that



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leads to more serious penalties, such as the cancellation o the driving licence whenaccumulated points pass predetermined limits. imilarly the law could speci y amore serious penalty or repeat o enders. n general it is simpler to speci y a xed

ne or non-compliance with wearing laws to make sure that the en orcement andadministration procedures are straight orward.

In France, increased en orcement led to the numbero nes or non-use o seat-belts rising by 15% rom

2002 to 2003, and in July 2003 there was also anincrease rom one to three penalty points added to adriver’s licence or not wearing a seat-belt As a resulto these measures, the use o seat-belts by ront

seat occupants went up to 90% in urban areas andto 97% outside urban areas Wearing rates continued

to rise and by 2006 the urban rate was 94%, andoutside urban areas 98% o ront seat occupantswere wearing seat-belts ( 3 )

CASE STUDY: France: en orcement o seat-belt law

Consultation with stakeholders is crucial when developing the law and setting penalties. When implementing and starting en orcement o a new or revised lawthe legal arrangements could allow or a preparatory period when warning noticesare given to o enders instead o nes. Tese notices would usually in orm motorists

that there had been a change in the law and that in uture a penalty will be imposedor breaking it. Alternatives to nes can also be speci ed, such as the requirement to

attend accredited driver training courses. ox . shows some examples o seat-beltlegislation speci ying the penalties applicable to drivers in non-compliance.




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KENyA

Text:

(2) The owner o any motor vehicles used or drivenon a road contrary to paragraph (1) shall be guiltyo an o ence and liable to a ne o one thousand

shillings or every seat that is not tted or, i tted, isnot o the proper standard or speci cation

(4) A person who does not wear a seat-belt as requiredunder paragraph (3) shall be guilty o an o ence andliable to a ne o ve hundred shillings

VIET NAM

Text:

Punishment in the orms o warning or monetary ne rom VND 10,000 to VND 30,000 shall be applied tothe driver and the occupant o the ront seat in the vehicle equipped with seat-belts who do not asten theseat-belts while the vehicle is running

BOX 4 5:Example extracts o laws on penalties


Source: Article 9 – Fines applicable to drivers o automobiles and vehicles having similar structures which violate roadtra c rules; Chapter II – Administrative nes applicable to violations o road tra c rules; Decree No 15/2003/ND-CP,

issued by the Government prescribing administrative nes applicable to violations o road tra c rules

4.2.5 Developing and implementing legislation

Te requirements or ensuring that the legislation is enacted and that it will be vigorously en orced are:

strong support rom the highest levels o government, sending a clear message to•

society that seat-belts and tra c sa ety are vital national issues;su cient public support to ensure that en orcement o the law will be accepted by•

the majority;su cient commitment rom the en orcement and communication agencies to•

ensure their ull participation.

Te timescale and phasing o the seat-belt programme will depend on how easy ordi cult it is to meet these requirements (see next section).

Te ollowing questions should be considered when trying to meet theserequirements and appropriate actions taken:

Which agencies will be most e ective and in uential in implementing legislation?•

Are the capabilities o the agencies adequately addressed in the legislation?•

s the proposed legislation worded in an appropriate way, so as to gain support?•

What are the proposed penalties or motorists disobeying the law? Are these•

penalties appropriate and are they likely to be e ective?Has there been su cient consultation with stakeholders, politicians and the public?•



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Te advocacy activities o the working group will be essential in promoting andgaining approval or the legislation. Members o the group who are governmento cials, policy-makers, or injury prevention specialists will have the greatestin uence in convincing others o the need or a law.

Adequate public awareness must be ensured in order to optimize the success o thelaw and consultation and in ormation programmes must be integrated when the lawis being developed. Te Costa Rica case study gives an example o promotion o seat-belt wearing be ore legislation was passed and en orced.

In 2003–2005 the Government o Costa Rica leda success ul programme to reintroduce a seat-beltlaw The country’s previous seat-belt law had beenabolished some years earlier a ter it was ruled tocontravene constitutional reedoms, and the subse-quent drop in seat-belt use had been blamed by thegovernment or a rise in road casualties

To build public support or a new seat-belt law, the

government assembled a coalition including theRoad Sa ety Council, the tra c police, the NationalInsurance Institute and the Costa Rican AutomobileClub to promote an awareness campaign about theindividual and societal bene ts o using a seat-beltThis campaign was intended to both build support orproposed new legislation and prepare the population

or uture police en orcement The campaign wasentitled “Por Amor Use el Cinturón” (For love use yourseat-belt) Publicity materials, including televisionand radio adverts, billboards and newspaper adverts,

were complemented by a media relations campaignpromoting seat-belt use The tra c police distributedadvice leafets to drivers encouraging them and theirpassengers to use their seat-belts

Legislation was passed in April 2005 and by May,a ter a two-week grace period to allow or urtherawareness raising o the new law amongst motor-ists, the police began en orcement, issuing nes

or non-compliance Surveys conducted be ore thelegislative and publicity campaign and then againa ter the introduction o the new law showed driverseat-belt use during the period rising rom 24% to82% ( 4 )

CASE STUDY: Costa Rica: seat-belt legislation, awareness raising anden orcement

Automobile Club of Costa Rica (both photos)




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The need to consult be ore implementation o a seat-belt law is illustrated by the case o the Bahamas,where implementation o the mandatory seat-beltlaw was suspended or our years a ter it was passeddue to concern about the level o penalties and lack

o exemptions Amendments have been passed toaddress these issues and to improve the regulationsconcerning children in accordance with internationalrecommendations ( 5 )

CASE STUDY: Bahamas: need or adequate consultation

4.2.6 Phasing implementation

n practice many countries have phased in both tting and wearing seat-beltlegislation. For tting laws this has happened largely because the initial priorityrelating to reducing road tra c crash atalities and injuries was to protect caroccupants. Tese laws were then extended to buses and trucks.

Wearing laws have also ofen been phased in by type o occupant, with ront seat wearing being made mandatory be ore rear seat wearing and child restraints.

Campaign planners believe that the best approach is to see ull vehicle occupantlegislation (covering ront, rear and child vehicle occupants) introduced in a single phase. Tis sends a consistent message that seat-belts save lives and injuries whatever

the location o the occupant and avoids the possible misperception caused by tieredlegislation implying that it is not as necessary to wear a seat-belt in the rear as in theront. However, historically most governments have considered this too much to ask

o the driving public immediately and have adopted a phased approach. A typicalexample o phased legislation is shown in the case study rom Australia.



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In 1959, the Senate o the Commonwealth Parlia-ment in Australia established a Select Committeewhose primary aim was to investigate the most e ec-tive ways o promoting road sa ety in the country TheCommittee (1960) recommended that “the motortrade should install seat-belts o an approved stand-ard in all motor vehicles Road sa ety authoritiesshould give publicity to the advantages o wearingseat-belts ”

Australian Standard E35 (Sa ety Belts) was intro-

duced in 1961 and was very similar to that usedin the United Kingdom (BS 3254) A standard withspeci cations or anchorages (D11) was producedin 1967 To ensure that seat-belts con ormed tothis, the Standards Association o Australia (SAA)registered a certi cation mark that would be used

by manu acturers who were approved by the SAA,enabling consumers to identi y seat-belts that weremanu actured to the national standard

Starting in 1962, the Australian Road Sa ety Councilproduced a monthly journal attempting to gener-ate awareness o seat-belts and their bene ts, andreported on work undertaken to try and achieve thisThe journal, Report , continued or over a decade

A ter a recommendation by the Victorian Joint SelectCommittee or Road Sa ety (1969), legislation wasintroduced (1970) making it mandatory or vehicleoccupants to wear seat-belts Soon a ter, similar leg-islation was introduced in New South Wales (1971)By 1972, seat-belt wearing legislation applied to thewhole o the country

CASE STUDY: History o seat-belt legislation, Australia

t is important that an appropriate time rame be developed or enacting the law.Te time rame rom implementation o the law to ull en orcement and penalty

or non-compliance can be anything rom a couple o months to several years. Tis will depend on the situation in the country, and must be articulated in the overallaction plan.

4.2.7 Section summar : checklist or seat-belt legislation

A checklist or seat-belt legislation might be as ollows:Aim to develop seat-belt and child restraint laws to make restraint usage universal.•

eat-belts and child restraints reduce death and injury severity in road crashes.Aim to develop and enact legislation that deals with the three main issues: seat-•

belt tting by vehicle type and inspection; seat-belt wearing by vehicle type, passenger location, children; and penalties or non-compliance. nclude legislation prohibiting carriage o children in ront seats unless placed in approved childrestraints, with airbags switched o .Use the gaps and weaknesses identi ed in the situation assessment to guide the•

development o a seat-belt usage programme and action plan.Consult with stakeholders when developing laws and setting penalties.•

Consider phasing in tting and wearing seat-belt legislation, with ront seat•

wearing being made mandatory be ore rear seat wearing and child restraint.However, introducing ull vehicle occupant legislation is believed to be the bestapproach as it sends a consistent message and avoids possible misperceptions.




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Requirements or ensuring legislation is enacted and will be en orced include•

strong political suport, su cient public support, su cient commitment rom thetra c police and advocacy through communications agencies.Consider the level o severity o penalties or non-compliance. Penalties must be•

perceived as su ciently serious to deter would-be law-breakers and consistent with penalties or other tra c law violations.Consider care ully any justi cations or exemptions to seat-belt laws. Widespread•

exemptions are not advisable as they could undermine the e ectiveness o a seat-belt programme.

4.3 Seat-belt standards and equipment

Tis section is or practitioners and campaigners who are responsible or the overalldesign and implementation o a seat-belt programme. t there ore aims to introduceseat-belt standards rom a general point o view. A more detailed and technicalexamination o seat-belt standards should be undertaken by technical specialists.

Te in ormation provided in this section o the manual re ers to the manu acturing and tting o seat-belts. t aims to give guidance and recommendations on the use

o legislation and standards to increase the sa ety o vehicle occupants. Te key toachieving success is consultation and partnership with vehicle manu acturers. countries can ensure that vehicles sold in their country have seat-belts installed asstandard, manu actured to the speci ed regulations set out within legislation, thenstakeholders can start to work towards increasing wearing rates.

takeholders should note that ease o use and com ort will inevitably a ect wearing levels. Tere ore, recommendations are based on types that have provedto be e ective in providing satis actory support in a crash and that minimizeinconvenience to the vehicle occupant when astening and wearing.

Tis section provides in ormation on:adopting a standard or regulation ( . . )•

types o standards or regulations and their content ( . . )•

esting and certi cation ( . . )•

vehicle inspection and seat-belt maintenance ( . . )•

retrospective tting ( . . )•

in-vehicle reminder systems ( . . ).•



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4.3.1 Adopting a standard or regulation

One o the objectives o a seat-belt programme might be to raise the quality o theseat-belts being used. Tis is best achieved by ensuring that all seat-belts meet arecognized sa ety standard – one that has been demonstrated as being e ective inreducing injuries.

tandards mostly include technical requirement speci cations and test methodsregarding the construction and installation o the di erent seat-belt types and theircomponents.

A ew questions to ask when developing, adopting or revising a seat-belt standardinclude:

Does a national standard exist?•

Does the national standard meet international standards?•

Are vehicle standards en orced and are they adhered to by vehicle manu acturers•

and distributors?Are consumers aware o the standard?•

the situation assessment (Module ) reveals shortcomings in the tting o seat-belts and their components then a specialist committee should be established as parto the working group (Module and Figure . ) to make decisions about adopting orrevising standards and strengthening control mechanisms or improving compliance.Tis committee should include appropriate technical experts rom key government

agencies, standards specialists and representatives rom vehicle and componentmanu acturers.

Consultation with vehicle manu acturers and distributors is crucial to ensure that astandard is not so stringent as to restrict production and availability.

deally stakeholders should harmonize with one speci c standard to ensureconsistency at a global level. t is recommended that countries base standards onthe United ations Economic Committee or Europe (U ECE) regulations. Teappropriate U ECE body to establish uni orm prescriptions regarding new motor vehicles and motor vehicle equipment is the World Forum or Harmonization o

Vehicle Regulations (WP ). More details on these regulations are provided insection . . .




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UNECE regulations

The UNECE regulations under the 1958 Agreement ( 6 ) cover the ollowing:

(a) wheeled vehicles, equipment or parts concerned;

(b) technical requirements, which i necessary may include alternatives;

(c) test methods by which any per ormance requirements are to be demon-strated;

(d) conditions or granting type approval and their reciprocal recognition,

including any approval markings and conditions or ensuring con ormity o production;

(e) the date(s) on which the regulation enters into orce

Each Contracting Party to the Agreement (see note on U ECE regulations)can decide i it wants to apply a U ECE regulation (its application is there oreoptional). A Contracting Party that decides to mandate a regulation on its territorymust do so by transposing the regulation to its national or regional legislation.

Countries can make additions to these standards; this may be necessary to meetlocal environmental conditions (see note on environmental conditions). n addition,countries can consider harmonizing their standards and regulations in stages. ndia,

or example, has adopted a three-stage process (see case study rom ndia).

Standards and environmental conditions

When adopting standards, stakeholders should assess the e ects o theirnatural environment on the seat-belt components For instance, prolongedperiods o ultraviolet (UV) light rom the sun can reduce the li espan o a seat-belt unless treated The heat rom the sun can also distort some types o materials Australia has adopted the UNECE regulations, but added to themto ensure suitability within their environment



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Table 4.2 Contents o UNECE Regulations 14, 16 and 44

Contents o regulationsReg. 14 Reg. 16 Reg. 44

Anchorages Installation Childrestraints

Application or approval:

The technical details required within an application bythe manu acturer, also highlighting measures to controlcon ormity

4 4 4

Approval:

Labels stating approval, granted by a speci ed authority 4 4 4

Markings:

Indicates the obligation on the manu acturer to providedetails about the product

4 4

Speci cations:

Speci ed requirements o the product 4 4 4

Testing:

Highlights the type o tests required to be undertaken orindividual components and products, speci ying the minimumand maximum results o con ormity

4 4 4

Inspection a ter testing:

Evaluation and documentation o testing results 4 4 4

Modi cations:

Manu acturers obligation to in orm the approval authorityand document any modi cations to a product that have beenapproved

4 4 4

Installation:

Outlining the requirements o installation dependent on theseat type

4

Con ormity o production:

Identi es the obligation on the manu acturer to implementcontrol measures to ensure con ormity

4 4 4

Penalties or non-con ormity:

Outlines the penalties en orced or non-compliance 4 4 4

Operating instructions:

Standard instructions to be provided by the manu acturer tothe product user

4 4 4

Production discontinued:

The obligations on the manu acturer to in orm the approvalauthority that a product has ceased to be manu actured

4 4 4

Transitional provisions:

Periods o notice given to manu acturers to comply withamendments to regulations

4 4 4




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India has established a harmonization process orour-wheeled (or three-wheeled i the weight exceeds

1 tonne) passenger vehicles Regulations AIS 016(seat-belts) and AIS 015 (anchorages) have beendesigned to harmonize with UNECE regulations As

such, India has introduced legislation to ensure thatvehicles sold within the country meet the require-ments o these standards using a three-tiered(phased) approach with targets set or 2003, 2005and completion in 2010

CASE STUDY: Harmonization o standards with UNECE regulations, India

4.3.2 T pes o standards or regulations and their content

U ECE has developed and regularly updates three key regulations under the Agreement: , and (see able . ), on the design and installation o seat-belts,their anchorages and child restraints or its Member tates (– ).

Tere are currently countries rom various regions o the world that have accededto the Agreement, including countries in Asia and A rica, or example Malaysia,the Republic o Korea, Tailand and unisia.

For more extensive in ormation on the regulations see the U ECE web site: http:// www.unece.org/trans/main/wp /wp regs.html.

ome examples o standards or seat-belt components are shown in able . .

Table 4.3 Seat-belt components and example quality standards

Component Example UNECE standards

Buckles

Section 6 2 2 o UNECERegulation 16

Easy to engage and disengage and be designed to minimize injury to theuser

Single-handed operation is possible or ront seat occupants

Release buttons are red (easy to locate)

Maximum and minimum orces or operation o the release button

Adjustment system andpretensioners

Section 6 2 6 o UNECERegulation 16

Seat-belts must not be slack when worn to be e ective

Retracting seat-belts with automatic locking systems are much morecom ortable or users

Load limiters allow controlled release o the webbing to minimize orceson the user

Anchorages

Annexe 3 o UNECERegulation 14

The standard prescribes the appropriate structural position o theanchorage points and the type o bolts used or astening

Lap straps must be positioned to prevent wearers rom slipping under thebelt and shoulder anchorage should be above shoulder height to avoidcompressing the spine in a crash



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4.3.3 Testing and certifcation

Te testing and certi cation process is employed to en orce the seat-belt regulations.t is recommended that countries introduce a type approval system or testing andcerti ying seat-belts and that an independent centre with well-trained inspectors isestablished to carry out the tests.

Tis approach requires manu acturers to submit a sample product to the designatedapproval department or independent testing and authorization using the testsspeci ed in the regulations.

ypical tests required or seat-belt certi cation are shown in box . .

D namic test

The test is per ormed on seat-belt assemblies toveri y the minimum displacement o the manikin andthat no part o the assembly, a ecting the restrainto the occupant, would break, release or unlock (para-graph 6 4 1 o UNECE Regulation16)

D namic strength test

The dynamic strength test uses a test dummy on asled, restrained by the seat-belt under test attachedto standard anchorages or those prescribed or use(paragraph 7 7 o UNECE Regulation 16)

The dynamic test may be per ormed a ter multipleoperations o the mechanisms (e g buckles, adjust-ers, retractors) to provide a control on the durabilityo the system (paragraph 7 5 o UNECE Regulation16)

Abrasion test

The seat-belt webbing should be subject to anabrasion test and, i thought appropriate, a sun-light degradation test (paragraph 6 4 2 1 o UNECERegulation 16)

Durabilit tests

Other mechanical parts o the seat-belt should besubject to durability testing, appropriate or the condi-tions under which they are expected to operate Thiscould include, or example, high or low temperaturesor a sandy environment or high humidity environ-ment, as these actors are known to a ect seat-beltper ormance (section 7 o UNECE Regulation 16)

BOX 4 6:Per ormance tests or seat-belts

testing identi es non-compliance, the product tested would not be type approved,or i the test is per ormed to veri y the con ormity o production, the product shouldbe removed rom production and sale until such time as it has been modi ed tocomply with the requirements outlined by the regulations. Tis would subsequentlyresult in a recall o that product i sales have been made (re er to section o U ECE Regulations and , and section o U ECE Regulation ).

eat-belts that are approved under the regulations must have a label attached with aninternational approval mark showing year o manu acture, approval number or theseat-belt type and manu acturer and the manu acturer’s serial number.



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Figure 4.4 Possible seat-belt damage

Damaged belt

Source: Securon Ltd

Poor retracting and lockingWeak connectionsDamaged buckles

4.3.5 Retrospective ftting

n countries in which a signi cant proportion o the vehicle eet are not tted with seat-belts, or only have ront seat-belts tted as standard, due to their date o manu acture, it may be necessary to consider a requirement or retrospective tting

o seat-belts (i.e. tting o seat-belts afer the point o manu acture and sale). eat-belts will not be e ective unless they are installed in accordance with an appropriatestandard (see box . ). When choosing the type o seat-belt, the level o protectionmust be considered against the practicality o tting and the cost o the conversion.




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Where e ective and controlled retrospective ttingcan be achieved, the ollowing recommendationshave been made in the Australian and New Zealandstandard AS/NZS 2596 (10):

The belt should be anchored to a substantial part•

o the metal body or rame o the vehicleAnchors or lap belts and lap sections o other•

assemblies should be at least 380 mm apart,where practicableThe shoulder anchor point o lap and diagonal belts•

should be located at or about shoulder heightso that, or all sizes o wearer, the torso strappasses across the chest like a sash and over theshoulder to the anchor The height o this point inrelation to shoulder height depends partly uponthe distance between shoulder and anchor Fortall wearers, the torso strap may o necessityslope downwards rom shoulder to anchor; 15degrees is recommended as the maximum anglebelow the horizontal Torso straps o harness belts

should similarly be anchored at or about shoulderheightEach anchor point in the vehicle should be capable•

o withstanding a orce o at least 12 5 kilonew-tons (kN) without racture Unless the vehicle hasinbuilt anchorages, the use o rein orcing platesor other devices is essential to prevent the beltanchors pulling out o the vehicle body or rameThose provided with the assembly should beusedWhere anchor ttings rom two adjacent assem-•

blies are to be connected to the same anchorpoint in the vehicle, the anchor should be capableo carrying the combined orce o the two assem-blies, i e 25 kNVehicle seat structures are usually inadequate or•

carrying seat-belt loadings and should not be usedas anchors unless the vehicle manu acturer hasprovided inbuilt seat-belt anchors in the seat

BOX 4 7:Standards or retrospective tting o seat-belts

Rear seat-belts will be made compulsory in Malaysiaor all car occupants starting on 1 January 2009

However, vehicles produced be ore 1 January 1995will be exempted, as many were not equipped withrear seat-belts or anchorage points Vehicles pro-duced a ter this date that do not have anchorage

points will also be exempt Among this older group o private vehicles (produced post-1995), about 10% arebeing retro tted with seat-belts ree o charge througha smart partnership involving the Road Sa ety Depart-ment and car manu acturers Vehicle owners havebeen given three years to retro t the seat-belts

CASE STUDY: Malaysia: retro tting o rear seat-belts

Te minimum legal requirement or seat-belts in coaches should be to t a two-pointlap belt. A three-point lap and diagonal seat-belt does o er greater protection but itmay not be easible to retro t these types o seat-belts on older coaches. A two-pointlap belt will assist in restraining the occupants within their seats and signi cantlyreduce the likelihood o death or injury.



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To illustrate the bene ts o seat-belt compliance,in 1994 the United Kingdom’s Department orTransport conducted an analysis o the nancialsavings made through mandatory retro tting and90% usage o seat-belts in coaches, minibuses and

vans Installation costs were compared to casualtycosts This highlighted a casualty saving o US$ 5250 000 in coach crashes alone (giving a net bene to US$ 1 725 000, taking into account installationcosts) ( 11 )

CASE STUDY: Cost–bene ts o retro tting seat-belts in buses,United Kingdom

4.3.6 In-vehicle reminder s stems

everal devices have been developed in recent years to remind vehicle occupantsto buckle up. ypically they comprise a ashing light on the dashboard and a loud warning tone, which can increase in intensity with higher speeds. nitially theyoperated only or the driver’s seat but new systems can be applied to any seat.

n more than hal the new cars sold in Europe were tted with remindersystems to warn drivers that they have not buckled up their seat-belt. a ety expertssuggest that the reminders will work with drivers and passengers who orget butthey recognize that they are unlikely to a ect hard-core non-wearers. Japan madereminder systems mandatory or the driver’s seat in . All countries shouldconsider similar legislation and should not add additional taxes or these items or orseat-belts, or example by classi ying them as luxury items.

A Swedish study indicated that reminders giving audible and visual signals increased wearing levels rom 77%

to 88%, according to ambulance personnel reports rom crash scenes Wearing levels seemed to be virtually

unchanged or systems that gave only visual signals ( 12 )

CASE STUDY: In-car seat-belt reminders increase wearing levels, Sweden




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4.3.7 Section summar : checklist or developing seat-belt standard orregulation

A checklist or developing a seat-belt standard or regulation might be as ollows:Examine current seat-belt manu acturing and tment standards and guidance.•

Determine whether an existing standard needs revision or a new standard has to•

be developed.Determine current levels o vehicles tted with seat-belts.•

Determine current levels o vehicles with anchorage points only.•

Calculate the cost o retrospective installation or vehicles with anchorages only•

and establish realistic consumer costs.Lobby government and increase support to establish a working party to address•

the need or the introduction o technical standards or the manu acturing andtting o seat-belts and child restraints.Establish a working party (which should include manu acturers and consumer•

groups) to identi y the ability o the country or state to conduct regular vehicleinspections, outlining improvements to be made.Develop and agree an action programme with targets and realistic timescales.•

Develop and agree standards or regulations based on U ECE Regulations , •

and .Lobby or legislation to be introduced that incorporates the appropriate changes•

and ensure that the standard is included in national legislation.Establish a procedure or testing and certi cation o seat-belts by a regulatory•

agency and or en orcement o the new standard or regulation.Agree a timescale or manu acturers and retailers to con orm to new standards.•

Produce and disseminate in ormation on the new standard to manu acturers,•

retailers and the public. vehicle inspection is mandatory, establish a procedure or inspecting seat-belts•

and implement guidance and training or inspectors.Produce seat-belt inspection guidance or vehicle owners.•

Encourage private and public sector organizations to play an active role in•

promoting and controlling the use o seat-belts that meet international standards.Monitor and evaluate the e ectiveness o the standards and regulations•

programme.



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4.4 Increasing usage: en orcement

The combined approach to increasing seat-belt usage




Mandatory Voluntary

Penalties & nes

Insurance &incentive schemes





Te most e ective tool or increasing compliance is en orcement, especially when itis supported by voluntary measures, in particular targeted publicity and educationcampaigns. Tis section deals with en orcement.

4.4.1 Pre-requirements

Tree essential requirements prior to starting the en orcement campaign are:Lead by example• . Government and other agencies, particularly thetransportation, health and police departments, should take the lead and make seat-belt use compulsory or their own sta under their contracts o employment, andthey should be seen to wear them at all times.In orm the public about enhanced en orcement• . Motorists should be in ormedin plenty o time about new laws, changes in en orcement and the penalties ornon-compliance through appropriate media.

Raise public and political awareness and support• to a su cient level to ensurethat the en orcement campaign will be acceptable.




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4.4.2 En orcement strateg

trategic tra c law en orcement can and does make a di erence i it ollows good practice. For e ective implementation o seat-belt laws:en orcement must provide a meaning ul and deterrent threat to non-seat-belt•

wearing motor vehicle users;the perceived risk o apprehension and prosecution must be high.•

Te objective o a proactive seat-belt law en orcement intervention is to ensure thatseat-belts are worn by all vehicle occupants on all roads at all times.

Te outcome sought is an increase in seat-belt wearing, which will lead to areduction in injuries, road trauma and deaths.

Apprehending o enders is a by-product o the intervention, not the main objectiveitsel . As the intervention proves to be success ul, apprehensions should decline andallow police to change the priorities o their strategy.

En orcement should be “intelligence led”, which requires:Understanding which occupants are most at risk and the groups who are not using •

seat-belts through data collection and analysis. Police crash reports must includein ormation about seat-belt usage at the time o the crash.Understanding community perceptions and political commitment regarding •

seat-belt wearing. Public pressure on politicians can lead to greater support ormore intense en orcement o seat-belt laws. Political will is critical in ensuring aconsistent and rigorous en orcement process.

G e o r g e I n s t i t u t e



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Moving rom the introduction o a new law to its ull en orcement can be a lengthy process depending on the position o the politicians and the public regarding the law.Compliance with the law should be built up in planned stages to ensure su cient political and public support.

En orcing a seat-belt law creates an extra burden on the police. t is use ul in advanceto examine the capacity o the police orce, to explore how to integrate seat-belten orcement into current policing activities, and to determine whether resources areavailable or possible additional recruits. n any case, tra c police will need training in the new law and how best to en orce it.

How well the police can cope will help decide whether to introduce a blanketen orcement o the law or to take a phased approach. Phased en orcement shouldtarget those areas where seat-belt wearing rates are known to be low and wherecasualty rates among vehicle occupants are high.

Police action afer apprehending violators can also be phased. ypically whenen orcement commences police can start by issuing warnings and explaining the newlaw and then afer a time agreed in the legislation they can issue the appropriate nes.

ncreasing the severity o the nes can also help increase wearing levels but this willusually be implemented through the legislation process (see section . . ).

However, it must be noted that phasing in legislation, and allowing certainexemptions rom laws, are steps that themselves introduce a set o concerns with

regards to en orcement. En orcement may be more time consuming and moredi cult i there are di erences in where the law applies, or i there are people whoare exempt rom the law.

enior police o cers must take a lead in the initial planning and implementation o intervention strategies. A “champion” in the police eld will ensure ownership withinthe en orcement community and assist in ensuring the sustainability o a national orstatewide campaign on seat-belt wearing. Police commanders must appreciate thecost o en orcement compared with the cost o rescue operations, medical treatmentand rehabilitation o the injured.

raining in e ective strategic law en orcement may also be help ul in obtaining andmaintaining the commitment o police o cers to en orce the seat-belt laws.




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The rst ormal en orcement campaign (primary law)in the United States was conducted in Elmira, NewYork, in the 1980s The approach used in this countywas later used as a model or other campaignsacross the country Williams et al (2000) ( 13 ) high-lighted the success o this campaign, with ront seatwearing rates increasing rom 49% to 80% However,the en orcement programme was not maintained,and wearing rates ell to 69%

In 1997, the National Highway Tra c Sa ety Admin-

istration (NHTSA) initiated the Buckle Up Americapublic health and sa ety campaign designed toincrease seat-belt use nationwide The campaign,now called Click It or Ticket, was built around a our-point strategy that is still the oundation o NHTSAcampaigns ( 14 ) The rate o seat-belt use increased

rom 61% in 1996 to 82% in 2005

Point 1: Enact strong legislation

It is imperative to adopt primary en orcement seat-belt use laws and to close the gaps in child passengersa ety laws in all states Police o cers should beable to write a citation whenever a seat-belt violationis observed, whether or not the driver has committedany other tra c in raction Child passenger sa etylaws should cover all children up to age 16 years inevery seating position

Point 2: Build public–private partnerships at thelocal, state and ederal levels

The goal o increasing seat-belt use is too big orany one group or agency to accomplish alone But

working together, the nation can achieve higheruse through stronger laws, visible en orcement andpublic education and in ormation Partnerships orcoalitions can set the tone in a community, work-place or organization, and the media can help spreadthe message that the proper use o seat-belts andchild sa ety seats are imperative or maintainingthe health and well-being o amilies and other com-munity members

Point 3: Conduct active, high-visibilit en orcement

Experience has shown that, a ter seat-belt use lawsare passed, seat-belt use increases quickly But with-out active and sustained high-visibility en orcement,it soon drops again Seat-belt laws must be visiblyen orced the way other tra c laws are (red lightrunning, speeding, etc ) In addition to increasingseat-belt use and reducing crash injuries, high-visi-bility en orcement results in a measurable reductionin crime (one third o criminal apprehensions occuras part o tra c stops)

Point 4: Expand e ective public education

It is critical to educate the public about the bene tso seat-belt and child sa ety seat use Public educa-tion may include a broad range o activities such asen orcement campaigns, promotional events andcommunity-based initiatives These activities aremost e ective when they are well planned and coor-dinated and use a simple message that is repeatedmany times in di erent ways

CASE STUDY: Seat-belt campaign strategy, United States



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4.4.3 En orcement methods

trategic law en orcement integrates our undamental principles o policing in amultidimensional intervention ( able . ).

Table 4.4 Four undamental principles o law en orcement

Principle Elaboration o principle

Increased visibility oen orcement

This includes highly visible, publicly observable and strategically locatedcheckpoints and roadblocks

These must be varied in location, intensity and time o day or nightThere should be many police o cers in each working team

Visibility includes signage about the en orcement activity, sa ety vests orpolice and adequate lighting at night

Repetition o en orcementcampaigns

This indicates to motorists that the risks o being caught are high –anywhere, any time

Strict and consistenten orcement

A ter an initial public warning period, police en orcement should be strict,non-discriminatory, air and consistent – not just short term, on highwaysor where police en orcement can be anticipated

I there is no en orcement, there will be limited or no compliance

Well-publicizeden orcement

To achieve maximum e ectiveness, compliance-driven en orcementmust be combined with coordinated education and publicity campaignsinvolving the engagement o government, local government, the massmedia and other agencies

Publicity campaigns should be conducted be ore, during and a terpolicing activities with rein orced sa ety messages

Sa ety brochures on correct seat-belt use may be handed out with awarning as an alternative to issuing a ne

Education and instruction can include reminders o the bene ts o seat-belt wearing and the constant promotion o sa ety messages

As well as adopting these principles, the en orcement agencies, together withtheir collaborating partners, should agreeminimum annual targets or levels o compliance based on benchmark surveys o seat-belt wearing. Te en orcementstrategy should be results ocused and resource allocation should be driven by progress towards meeting the target.

uccess o law en orcement e orts is indicated by the level o compliance observablein the driving community and not by the number o in ringements or warningsgiven. Compliance is measured by the percentage increase in seat-belt wearing rates. Other per ormance measures are the number o checkpoint operations,target operations, educational lectures and individual and media warnings. Te police should also publicize the bene ts o their programme to encourage a strong community consensus or using seat-belts.




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Apprehension o violators o the seat-belt laws will largely be done through checkpoints and roadblocks, mobile highway patrols and police stationed at locations where vehicles stop, such as service stations, tollgates and tra c signals.

En orcement operations should be well planned, with all tra c o cers being appropriately trained and brie ed. a ety should be paramount, with dueconsideration given to the sa ety o the interception o cers and the driving public,the sa e use o equipment and the selection o checkpoint sites.

4.4.4 Police training

Police o cers must be trained in e ective strategies and tactics to achieve maximum

success. Tese include:knowledge o the law;•

understanding how seat-belt wearing reduces the risks o injuries (even in low-•

speed crashes); police o cers on and o duty must obey the law and must set an example;•

understanding how to set up sa e and e ective roadblocks and checkpoints or•

maximum on-road public exposure and en orcement. Tis will include signage orlarge banners indicating to all the driving population what en orcement is being undertaken, e.g. “ eat-belt checkpoint” or “ eat-belts save lives”;how to target areas with high rates o non-compliance;•

how to provide e ective advice and education to motorists;•

understanding the impact o crashes on nancial and human resources, both•

as regards the community and as regards the resource savings to police andemergency rescue services when an e ective law en orcement programme isundertaken.

4.4.5 Processing penalties

Choosing penalties is dealt with as part o the legislation process in section . . As well as considering phasing in more severe penalties, it is important that penalties are processed quickly and equitably regardless o the status o those who have broken thelaw. Fines can be collected quickly and e ciently without a court process through aticket system or by on-the-spot nes, as ollows:

Written tickets can be issued on the spot, requiring the o ending driver to pay•

a ne to a given department or bank by a speci ed date or submit to another penalty such as a driver training course. o operate this method e ectively, acomputerized database should be set up to record all o ences. Fixed penalties canuse a combination o nes and demerit points.On-the-spot nes are levied in some countries whereby motorists caught driving •

without wearing seat-belts have to pay a ne directly to the police o cer. Temoney is then passed on to the transportation authority.



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Te ormer method is pre erred as the opportunity or corruption is somewhatreduced and also it provides scope or including seat-belt violations in a penalty points system. t also enables alternative penalties to be issued, such as attendance at adriver training course.

4.4.6 Overcoming obstacles to en orcement

En orcement authorities will ofen have limited resources and checking seat-belt violations will compete with other policing priorities. Agreeing a national andlocal seat-belt wearing target is there ore crucial in obtaining commitment and thenecessary resources.

Political support is undamental to sustained outcomes. carce police resources mustbe used e ectively and e ciently to maximize the value o law en orcement operations.

able . shows some barriers that can arise when trying to implement a seat-belt law,together with their remedial actions.

Table 4.5 Overcoming barriers or obstacles to effective implementation of the law

Barriers Remedial actions

Limited police resources Strategic planning or intensive high-pro le, high-•

visibility en orcement activity – resource deploymentand coordinationCombining education and en orcement•

Strong media campaigns•

Community support campaigns•

Allocation o additional tra c o cers•

Competing police priorities Government and senior police o cers understanding•

the real economic and human costs o road traumacompared with the relatively lower costs o en orcementAppreciating the cost savings that can be achieved by•

strategic tra c en orcement

Complacency in en orcement Enhanced training o police o cers, supervisors and•

police management, with emphasis on the risks todrivers, their passengers and the community

Police o cer sympathy in avour o the

driver:Seat-belts stated to be uncom ortable,•

inconvenient or unnecessaryCost o nes•

Education o police o cers about the associated risks•

o not wearing seat-beltsCommunity education•

Inadequate or ine ective policing capabilityor strategies and the perception thaten orcement is too di cult with suchextensive non-compliance

Development o an integrated law en orcement strategy•

Identi cation and publication o minor successes•

Modelling on “good practice” examples o success•

Targeted seat-belt law en orcement•

Corruption, including:

Police o cers collecting nes and•

not passing them on to governmentauthoritiesIllegal and unethical receipt o monies as•

payment to overlook an o ence (bribery)

Anticorruption measures•

An appreciation that corruption undermines any road•

sa ety interventionEnhanced education and training o o cers•

Salary reviews o tra c o cers a ter appropriate training•

Promotion o a code o ethics/behaviour•




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4.4.7 Section summar : increasing seat-belt usage throughen orcement

Consistent en orcement o seat-belt laws by the tra c police is one o the moste ective methods o raising and maintaining high levels o wearing rates among vehicle occupants.

Te primary objective o en orcement is to ensure that seat-belts are worn by all vehicle occupants on all roads at all times. Te primary outcome o en orcemente orts is an increase in wearing rates, leading to a reduction in the number andseverity o road crash injuries.

A checklist o en orcement activities might be as ollows:

e ore starting an en orcement campaign government and other agencies should•

take the lead and make seat-belt use compulsory or their own sta ; the publicshould be in ormed about enhanced en orcement o the seat-belt law, any changesto the law, and penalties or non-compliance.

trengthen law en orcement e orts by developing a strategic, intelligence-led•

approach, including increased visibility o en orcement; repetition o en orcementcampaigns; strict and consistent en orcement; and well-publicized en orcement.Examine the capacity o the police orce to increase en orcement e orts and•

explore how to integrate seat-belt en orcement into other en orcement activities.Consider phasing in police action afer apprehending violators, such as starting by•

issuing warnings and explaining the new law be ore issuing nes.Consider nominating a “champion” in the police eld to ensure ownership within•

the en orcement community and assist in ensuring the sustainability o seat-belten orcement e orts.Ensure that penalties are processed quickly and equitably regardless o the status o •

those who have broken the law.Agree a minimum annual target or level o compliance based on benchmark•

surveys o seat-belt wearing.Agree a national and local seat-belt wearing target as a basis or obtaining •

commitment and the necessary resources.



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4.5 Increasing usage: voluntary measures

The combined approach to increasing seat-belt usage




Mandatory Voluntary

Penalties & nes

Insurance & incentiveschemes





Voluntary measures, including publicity campaigns, education and training,employer regulation and promotion schemes and insurance and incentive schemes,are critical in raising awareness and understanding o the bene ts o using a seat-beltin support o legislation and en orcement e orts, encouraging voluntary use, andultimately bringing about a sustainable long-term increase in seat-belt wearing rates.



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Road sa ety publicity re ers to the whole amalgamation o activities designed toin orm, advise, encourage and persuade the target audience to undertake a particularbehaviour. On its own, publicity is o limited e ectiveness, but it is an essential parto a coordinated programme in support o legislation.

A campaign that is undertaken only once – even i it includes dedicated en orcement– will not have a long-term sustainable impact on increasing seat-belt wearing;regular en orcement accompanied by a repetition o the key messages is needed.

Publicity campaigns are important and can be e ective even i legislation requiring

seat-belt use is not yet in place, through highlighting the humanitarian and economicbene ts associated with the use o seat-belts. t is through the use o such campaignsthat increased voluntary use is acilitated. A review o wearing rates in countriesshowed that the average level o voluntary usage prior to the introduction o legislation was % o the population.

t is vital to the success o seat-belt legislation that the bene ts are understood. yincreasing awareness stakeholders are reducing any potential resistance that mayoccur to the introduction o legislation at a later date.

Conducting a publicity campaign will require expertise in marketing or advertising,

development o speci c campaign objectives, articulation o the campaign messages,

A u

t o m o b i l e C l u b o f C o s t a R i c a




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identi cation o the target audience, speci ying a time rame or implementation anda methodology or evaluating the initiative.

4.6.1 Objectives o the campaign

A seat-belt campaign aims to persuade vehicle occupants to wear a seat-belt, andto modi y their behaviour through acceptance o the proven socioeconomic andhumanitarian bene ts.

Te most important aspect o any campaign is to have a clear idea o what thecampaign is meant to achieve. Te objectives may be stated in quanti able terms. Forinstance, the public might be told that “by December it will be required by law

that all car drivers and passengers wear a seat-belt”.For a campaign to be success ul, it is important to employ social marketing tools.

ocial marketing is an e ort to impact the culture o a community in order to persuade it to accept, modi y or abandon ideas, attitudes, practices and behaviour( ). For a campaign to ollow the principles o social marketing:

it must ocus on a single-minded proposition;•

its execution must be distinctive;•

its target audience must be clearly de ned.•

Various objectives are possible, depending on the existing legislation and rate o seat-

belt use. Tey include:to increase public awareness that seat-belts can prevent serious injury and death;•

to increase awareness that every driver and passenger is sa er with a seat-belt;•

to encourage people to purchase cars with seat-belts tted and to use them;•

to convey the message that use o a seat-belt is now mandatory;•

to in orm people that seat-belt use is now being en orced, and to explain the•

penalties;to promote en orcement o the seat-belt laws by the police.•

Each o these objectives should be quanti able. t is there ore necessary rst toascertain:

the current level o awareness o the sa ety value o seat-belts, their availability•

and cost, and the legal requirements or seat-belts (see section . . on marketresearch);the current level o seat-belt use, by both drivers and passengers, by seating •

position, in urban and rural areas;the current level o en orcement (see case study rom Argentina).•



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Luchemos por la Vida (Let’s ght or li e) was oundedin 1990 with the aim o promoting seat-belt use inArgentina Be ore starting the seat-belt campaign,a systematic observation o seat-belt use amongdrivers and ront seat occupants in Buenos Aires wasundertaken, and regular surveys have been carriedout every year since Observations were taken at di -

erent sites in the city, at both day and night times, onholidays and working days, and or di erent types o vehicles At least 4000 vehicles were surveyed eachtime Only 0 2% o car occupants were observed tobe wearing a seat-belt in November 1990

In March 1992, a ter a rst and very simple campaignon radio and television, percentages went up to 3 1%

or drivers and 2 2% or ront seat passengers

In July 1992 seat-belt use became a legal require-ment in both ront and rear seats and usage rose to32% without any en orcement The impact o the leg-islation was short lived due to the complete absenceo en orcement By July 1995 only 13% o drivers and11% o ront seat passengers were wearing seat-belts A new law and campaign raised rates again to

32% or drivers and 30% or ront seat passengersin April 1996, but again without en orcement ratesdeclined to well below 20%

Luchemos por la Vida launched a new campaign,“Let’s save 1100 lives by using the seat-belt”, in May1999 The campaign used intense television andradio coverage based on the objections, myths and

alse belie s o the majority o the population regard-ing the use o seat-belts, and provided in ormationon the consequences o not being buckled up in thecase o an accident There was also a campaignprompting people to write letters to the president,the governors and the city mayors stressing theirresponsibility or 1100 deaths each year due to lacko control o seat-belt use Advertising at the road-side and at tollbooths on highways was used, andthe campaign was helped by a high-pro le accidentin which a ormer president nearly died a ter beingejected rom his car The wearing rate or drivers roseto 27% in November 1999, but as be ore it graduallydeclined again to 22% in June 2004

As a result o campaigns and lobbying o the authori-ties, en orcement was initiated in Buenos Aires inOctober 2004 with advertisements and strong policeaction The e ect was measured by Luchemos porla Vida and at the end o the rst week rates were86% or drivers and 83% or ront seat passengersA survey o drivers showed that 98% consideredseat-belts to be use ul in case o an accident, and81% agreed with seat-belt en orcement

Although the en orcement e ort has not been sus-tained, wearing rates in March 2005 were still over75% Luchemos por la Vida attribute this to theawareness-raising campaigns that, over a long periodo time, have led to the change that was initiated bythe en orcement campaign becoming permanent andhabitual ( 16 )

CASE STUDY: “Let’s ght or li e” seat-belt campaign, Argentina

4.6.2 Creating campaign messages

e ore developing the communication messages or a seat-belt use campaign, theactors restricting seat-belt use need to be identi ed, through both local knowledge

and market research. Te key target audience also needs to be determined, orexample ront seat or rear seat vehicle occupants, or those employing child restraints(see section . . on assessing seat-belt and child restraint wearing rates).

Market research is used to determine the target audience’s knowledge o legislation as well as the opinions, belie s, ears and motivations o high-risk groups that are knownto be involved in drink-drive crashes. A rst step in this process is to identi y thetarget audience involved and then collect in ormation rom them that is relevant orthe campaign.




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Diagnostic testing

Te rst step in developing campaign messages is to assemble a small group o individuals representing the main target group. Te goal o discussions is to:identi y and understand why these individuals do not use seat-belts;•

understand the incentives that might be used to change the attitude and behaviour•

o the target group.

Develop campaign messages and materials

On the basis o the in ormation received rom the diagnostic testing carried out with the target audience, a range o messages and campaign materials can bedeveloped to encourage a change in thinking and behaviour in relation to seat-beltuse. Preparation o these products is commonly undertaken by advertising agenciescontracted by the road sa ety authorities.

Te draf campaign messages and materials should then be tested with small groupso individuals representing the target audience by an independent market researchagency contracted or this purpose. Te agency that created the materials must notbe allowed to market-test their own materials, as they are unlikely to be sel -critical. Te purpose o testing the materials is to determine the most e ective message andmethod or communicating to the target audience, and changing their perceptionand behaviour in relation to seat-belt use.

Te campaign message should:be simple, consistent and memorable;•

be appropriate to the conditions o the particular country, including its social and•

cultural standards;not cause o ence to any group;•

be relevant to the target audience chosen, and not necessarily aim to apply to the•

whole population.

t is use ul to make the message itsel the “brand” or the campaign. Te productbeing sold is “Wear a seat-belt”, not the government agency responsible or thecampaign. ailored and targeted messages ofen work best in road sa ety ( ).

The central human and emotional message o the cam-paign (Por Amor use el Cinturón – 'For love use your seat-belt') was based around the concept o love and responsibility, with a campaign icon eaturing a tra fc signwith a heart secured by a seat belt.

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4.6.3 Reaching the target audience

Te target audience must interpret campaign messages as relevant to them.Depending upon the budget, objectives and target audiences or the campaign, arange o media will usually be employed to convey its messages. ome media aremore appropriate than others or a particular target group; or example, newspapersmay be better or middle-aged people, cinema lms or younger people and radio orthose in rural areas. A competent advertising agency will be able to advise on the best way to reach di erent target audiences.

Te campaign should adapt its approach or changing audiences, while keeping themain message consistent. Te campaign, or instance, may initially operate in urban

areas, or among younger people. Di erent approaches would then be needed toconvey the same message to rural or older audiences.

The rst national seat-belt campaign in Poland started in the middle o September 2005 On the basis o research results showing that seat-beltwearing rates were lowest amongst young people sitting in rear seats thetarget group chosen was young people (18–24 years o age) and the message

was addressed mainly to those sitting in the rear seat Research showed thatthe main reasons why people did not buckle up were:

they thought they could control the tra c situation and they believed that•

they were in control o the risk;they lacked the habit o wearing seat-belts•

The campaign objectives were to increase the wearing o seat-belts and tomake wearing seat-belts a social norm by:

building awareness that road crashes are a real and unpredictable hazard•

and that non-use o a seat-belt can cause death and serious injury;re uting alse belie s and myths related to seat-belts;•

creating the habit o wearing a seat-belt in the rear•

Evaluation results showed that 93% o the targeted audience, i e youngpeople 18–24 years o age, was reached The declared utilization rate o seat-belts in the back seat increased rom 34% to 66%, while the observationalstudy showed an overall growth in seat-belt use rom 38% to 50% in the back,and rom 74% to 84% in the ront A 10% decrease in atalities was recordedin the campaign time, which is traditionally the period with the highest crash

atality rate in the country ( 17 )

CASE STUDY: Seat-belt campaign targeting young people who are rearseat passengers, Poland




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4.6.4 Creative concepts

Creativity within a publicity campaign is all too ofen overlooked. A review o publicity campaigns worldwide has highlighted a number o common creativeelements that can potentially orm the basis o uture campaigns ( able . ).

Table 4.7 Common themes or improved creativity in road sa ety publicitycampaigns

Common themes Desired outcome

Shock tactics such as visuals o crashdummies; real-li e representations

(see note on shock tactics)

Emotional response to stimulus

Law en orcement Moral decision Fear actor: the desire not to bebanned rom driving, wanting to retain independenceand status

Inconvenience (e g on-the-spot nes) Li estyle decision, not wanting a reduction in income

Awareness, education, ability to relate toonesel

Educational decision based on level o knowledge

Peer endorsement Creating social awareness and acceptability throughthe use o high-pro le gures such as sports starsor television personalities

Memory/recall Subconscious, almost automatic decision

Frequency o message/call to action Instant decision/compliance

Creativity applies not only to the concept but also to planning and choice o media, which will vary according to national setting and budget available. Market researchshould aim to indicate the types o media through which speci c demographicgroups can be reached, or example early morning radio or drivers on their way to work, with reminders through advertising boards at petrol stations and car parks.

Shock tactics

The use o shock tactics has been widely utilized in road sa ety publicity cam-paigns, based on the belie that high-impact images will make drivers relateemotionally to their responsibilities on the road However, what is most likelyto ensure the e ectiveness o any road sa ety campaign is clear understandingand credibility o the message or the speci ed target audience

Simply using shock tactics to deliver a message can accustom the targetaudience to the shock, and there ore each subsequent advertisement has tohighlight more shocking images to have the same e ect



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Cost can be a major actor in considering which media to use. Research has suggestedthat low-cost publicity can be just as e ective as high-cost campaigns, provided thatthe target audience understands the message (8). More widespread disseminationo road sa ety messages can however be achieved through a large budget, althoughgovernment and corporate assistance can reduce advertising costs signi cantly.

Role model initiatives

Using selected role models can infuence people to wear seat-belts be orelegislation is introduced The particular role models chosen will depend on thegroup being targeted in the campaign The target group could be young people,who usually make up a signi cant proportion o drivers and passengers involvedin crashes In this case, the role models publicly seen wearing seat-belts mightbe well-known singers, lm or television stars or sports stars For a di erenttarget group, the role models could be prominent pro essionals, doctors orsuccess ul business people Young parents might be targeted with exampleso celebrities whose children are using recommended child restraints

A Jordanian awareness-raising campaign chose toblanket the whole country through television, radio,newspapers, mosques and churches This was par-ticularly e ective, increasing wearing rates by 47%Television advertising can prove costly; however, inJordan both television and some radio stations aregovernment owned and airtime was not included in

the costs o the campaign Three one-hour televisedmeetings were held, discussing the bene ts o seat-belts, plus 50 30-second adverts The most popularradio station was chosen to deliver road sa ety mes-sages through programmes o general interestThese lasted longer than those on television ( 20 )

CASE STUDY: Jordanian awareness-raising campaign




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The Sakhalin Island seat-belt campaign is supportedby the Sakhalin State Inspectorate or Tra c Sa ety(GIBDD) and Sakhalin Road Sa ety Partnership Thecampaign is undertaken annually and monitoringo seat-belt wearing rates is undertaken regularlythrough observational studies and through data col-lected by the tra c police during driver checks and atthe crash scene Components o the project includeeducation and awareness raising, en orcement ande ectiveness assessment

2005 seat-belt campaign

Be ore starting the development o this campaign,a detailed public opinion survey was undertaken

on Sakhalin Island to identi y the reasons that localresidents chose not to wear a seat-belt This wasrecognized as being o key importance in designing acampaign that would be e ective in addressing incor-rect assumptions and inaccurate belie s, allowing theproject team to tailor the initial campaign ideas andmessages accordingly Be ore the campaign launch,all campaign materials were thoroughly tested in anumber o externally managed ocus groups Thisensured that the materials and messages that hadbeen developed would be e ective in reaching theirtarget audiences (and where they were not, theproject team was able to make changes)

The campaign was implemented in two phases First,an awareness campaign was launched with high-pro le media coverage o key messages emphasizingwhy seat-belts should be worn and correcting alseassumptions about seat-belts held by members o the public Second, and most critically, an en orce-ment campaign was launched to rein orce the actthat the use o seat-belts was the law, and ailureto use a seat-belt would be punishable by a neThe project team identi ed that, although it wasRussian law that seat-belts should be worn, seat-belt en orcement was not regarded as a high priority

o the GIBDD due to lack o en orcement o cersThe head o the local GIBDD agreed to ensure thaten orcement o seat-belt usage on Sakhalin Islandwould be intensi ed during the en orcement phaseo the campaign

Research conducted be ore and a ter the 2005 cam-paign showed an increase in wearing rates in urbanareas (Yuzhno-Sakhalinsk) rom 3 8% to 13 9% andon rural roads rom 26 8% to 51 8%

2006 seat-belt campaign

In an e ort to bolster wearing rates a second cam-paign was launched in mid-2006 The project teamevaluated lessons learned rom the rst campaignand chose to ocus more e ort on:

ensuring consistent en orcement throughout the•

entire campaign period;creating stable positive opinions o the advan-•

tages o buckling up;reaching more people by using a larger range o •

mass media;implementing the campaign during the summer•

period, when crash rates are usually highest in theSakhalin Oblast

The geography o the 2006 campaign was expandedby conducting campaign launches in smaller commu-nities Video materials and radio clips were updatedto refect the summer season and higher level o en orcement The campaign star ted with active com-munications in local media and lasted rom Mayuntil the middle o November Additional researchwas undertaken during and a ter the campaign tomeasure the e ectiveness o the project and tostudy the opinion o the population with respect tothe approach taken in conducting the campaign

The public opinion survey showed that 86 7% o thepopulation had seen campaign materials, and thatthe most e ective means o communicating weretelevision, radio and billboards

The ollowing measures proved particularly criticalin developing and implementing two success ulcampaigns:

winning high-level political support or the•

campaign;

CASE STUDY: Seat-belt campaign, Sakhalin Island, Russia

G R S P

Continues…



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4.6.5 Selecting an agenc or the campaign

A success ul publicity campaign may be carried out by quali ed personnel within agovernment department, but usually needs the expertise o a pro essional marketing or advertising agency. Overall control o the campaign should, however, stay withthe government agency responsible. Te campaign may also require the services o a public relations agency and a research agency, unless the government agency can provide these services itsel .

Te rst step in selecting an advertising agency is to issue a tendering documentoutlining the overall aims and objectives o the campaign, the time schedule and thebudget. Te purpose o this tendering document is to assess the ability o responding agencies to do the work. From their initial applications, a shortlist o agencies shouldbe drawn up, based on:

the agencies’ previous experience with social marketing campaigns;•

their creative ability;•

their physical location;•

their media purchasing ability;•

their size.•

Te short-listed agencies are then asked to tender or the work by providing creativeideas, plans or media work and budgets.

Te steps involved in setting up a seat-belt publicity campaign are illustrated inFigure . .

engaging with local stakeholders representing•

diverse sectors;well-promoted and properly launched en orcement•

o tra c laws;pro essional development o campaign materials•

using ocus groups;pre- and post-campaign data collection on wearing•

rates based on international good practice;pre-launch educational events or media and local•

tra c police to raise the awareness o these keystakeholders about the risks involved in not wear-ing a seat-belt;high-pro ile media coverage using local true•

stories;debrie o key stakeholders a ter the campaign•

Research conducted be ore and a ter the 2006 cam-paign showed an increase in wearing rates in urbanareas (Yuzhno-Sakhalinsk) rom 14 3% to 22 7% andon rural roads rom 56 1% to 77 9% ( 19 ) Observa-tional studies in 2007 showed wearing rates had

increased to 64 8% prior to the 2007 campaign and jumped to 76 6% a ter the 2007 campaign

G R S P





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Figure 4.5 Steps involved in setting up a seat-belt publicity campaign

Publicity campaign agreedas component o seat-belt

programme

Initiate agency meetings to ensuresupport and understanding o publicity role

Conduct target group diagnostic researchto identi y pro le and motivations

Conduct communications testing researchto obtain likely e ective messages

Advertising agencycontracted or

materials production

Undertakeadvertising agency

appointment

E ectiveness o materialsis known

Commissionmaterials markettesting research

Initiate agency meetings to ensure supportand understanding o publicity role

Target group pro le andbehavioural motivations

are known

E ective communicationmessages are known

Good-quality,high-impact

campaign materialsare available

Most e ective media mix orcommunication is known

Commission advertising agencyto prepare media purchase planin accord with campaign budget

Commission media monitoring toensure media plan is deliveredCommission communications

e ectiveness research ascampaign is conducted

Yes

Yes

Yes

Yes

Yes

No

No

No

No

Yes

Yes

No

No

No

RunCampaign



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4.6.6 Working with the media

Te media – including the printed media, the broadcast media and the nternet –serve various unctions in any public education campaign. Tey will be interested inand will cover the campaign itsel – its objectives, contents and progress. Tey maysupport it, but they may equally be critical, to the extent even o running a counter-campaign. t is there ore important that the media are in ormed about a orthcoming campaign and that the reasons or the campaign are set out clearly and strongly.

An ongoing part o the campaign should be to keep the media regularly in ormedabout its progress and how it is meeting its targets. Tis can be done either by thegovernment agency or by an external public relations agency.

4.6.7 Campaign stages in relation to seat-belt legislation

Te stages o a seat-belt publicity campaign in respect to related activities suchas changes in the law and police en orcement should be care ully considered.Coordination among the initiatives is critical. Te stages should include some orall o those indicated in able . , depending on the current situation o seat-beltlegislation and en orcement.

Table 4.8 Campaign stages in relation to seat-belt legislation

Legislative situation Publicit activit and objectives

No seat-beltlegislation in place

Public education to encourage voluntary seat-belt use by:

explaining why wearing seat-belts is bene cial;•

in orming potential wearers about their availability and cost;•

giving in ormation on when seat-belt use will become compulsory•

New legislationadopted but not yetin e ect

An advisory stage as the date or new regulations approaches to:

ensure the date set or the introduction o the new legislation is one that is•

easily remembered;rein orce the importance o wearing seat-belts;•

explain the penalties or ailing to comply with the new regulations•

Legislation goes intoe ect

A marketing stage – probably the single most important stage – that should:

explain why wearing seat-belts is bene cial;•

give urther details on the consequences o not wearing seat-belts, both•

rom the point o view o possible injury and o the risk o penalty nes;rein orce the message or those who wear seat-belts only irregularly•

Note: During this stage, it may be best to en orce the regulations withwarnings only at rst, though the campaign will become most e ective whenthe regulations are ully en orced

Legislation rmlyin e ect

Periodic but regular maintenance to:

rein orce the message or those who wear seat-belts;•

remind those who have become lax in wearing seat-belts;•

continue to explain the consequences o not wearing seat-belts•

Note: Periodic marketing will rein orce a message, and is more cost e ectivethan continuous marketing




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Manu acturing legislation making it mandatory orcars built in Europe to have seat-belts tted in the

ront was implemented in 1965 Despite the newlegislation, wearing rates were low and in the early1970s a series o commercials were lmed using awell-known celebrity highlighting the dangers o beingthrown through a car windscreen This advertisingcampaign lasted or over a decade, increasing aware-ness o the bene ts o seat-belt use and preparingthe ground or legislation in 1983 making it compul-sory to wear seat-belts in the ront seat

Following legislation, ront seat-belt wearing ratesrose to over 90%, a level that has been consistentlymaintained In 1989 it became compulsory or allchildren under the age o 14 years to wear seat-beltsin the rear o a car, and compulsory rear seat-belt usewas extended in 1991 to include all passengersThese were primary laws and have been constantlyen orced

En orcement, education and publicity ormed thebasis o uture campaigns to increase wearing rates,

particularly amongst rear seat passengers and teen-agers Television and radio commercials were usedto show the risk to unbelted passengers, targetingall adults and parents

In 1998 only 43% o adults were wearing seat-beltsin the rear and a new campaign was developedResearch showed that many ront seat passengers

were killed each year by unbelted rear seat passen-gers colliding with them A campaign idea based onconveying the message about being responsible orinjuring someone else, and the degree o uncontrol-lable movement i unbelted at the time o a crash,was ound to be a power ul message As a resultthe “Julie” campaign, which showed a teenage boybeing thrown orward and killing his mother, wasdeveloped The campaign was highly success ul,increasing agreement that unbelted rear seat pas-sengers could “kill or seriously injure the driver”

rom 46% to 62% Importantly, rear seat-belt wearingincreased rom 48% to 59% a ter the campaign Theadvertisement continued to be shown until 2002,and by April 2006 the adult seat-belt wearing rate inthe rear was 69%

The latest television advertisement – “ Backward"– shows what happens to three young men in a carcrash when they are not belted in, then the sequenceis rerun with them wearing seat-belts The aim o theseat-belt campaign is to tell drivers and passengerso the importance o wearing a seat-belt both in the

ront and the back o a vehicle This is based on theinsight that the real crash happens inside the car(impact with the screen, dashboard and other pas-sengers) The strategy also seeks to target short tripsat low speeds in urban areas, as it is o ten on thesetypes o journeys that drivers do not belt up ( 21 )

CASE STUDY: Seat-belt wearing legislation and campaigns,United Kingdom



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The Touring and Automobile Club o Peru launchedthe Think Be ore You Drive campaign on 29 Septem-ber 2006 Campaign sta in dummy out ts took tothe streets with the tra c police to remind motoriststhat the new seat-belt legislation was coming into

orce as o 1 October 2006

This new legislation, which extended compulsoryseat-belt wearing to the back seats, was the result o the Automobile Club’s Por Amor seat-belt campaign,emulating the success ul Por Amor Use el Cinturón

campaign in Costa Rica in 2003–2005 (see casestudy, section 4 2 5)

A press con erence was held with the many partnerso the campaign, including the Head o Tra c Policeand the Health Minister, and both gave the goodexample o buckling up on the club’s seat-belt slideThe club demonstrated that in Peru, 3600 people dieand 600 000 people are injured in road accidentseach year This leads to a great deal o su ering andat times nancial distress among those who are le tbehind, but the country also su ers: the nancialloss due to the accident toll is estimated at up to

US$ 1 billion per year The club assisted the tra cpolice during their road checks on seat-belt use Onthe rst day o police en orcement 234 tickets wereissued, 70% to motorists who or some reason hadtaken out the seat-belts that their cars were normallyequipped with O the nes, 30% went to taxi drivers,who were also given a ticket i their passengers

were not wearing a seat-belt Most people waiteduntil the last minute to have seat-belts installed,which resulted in long queues at sales points andthe doubling o prices within two weeks As a resultthe Transport Ministry decided to delay phasing ininstallation o seat-belts in the back or some typeso transport, such as intercity buses, until November(10 )

CASE STUDY: Think Be ore You Drive campaign, Peru

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4.6.8 Evaluating the campaign

Monitoring and evaluation is an integral element o all road sa ety campaigns.t is through the implementation o monitoring and evaluation techniques that

stakeholders are able to determine the success or ailure o a campaign, and there oredesign uture campaigns accordingly.

Te primary outcome o a seat-belt campaign is seat-belts worn by all drivers and passengers. Tis outcome is best measured by regular, independently conducted,observational surveys, be ore, during and afer the campaign. deally, surveys shouldtake place at six-monthly intervals during the campaign, and annually once thecampaign has reached its maintenance stage. Te cost o surveys should be built intothe overall cost o the programme. Module described methods or carrying outobservational surveys.




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Te survey should be su ciently large to identi y signi cant di erences betweendi erent age groups, men and women, drivers and ront seat and rear seat passengers,cities and smaller towns, urban roads and highways, and di erent regions o thecountry. As di erences are ound in surveys, it may be necessary to adjust thecampaign ocus more towards those groups with lower seat-belt wearing rates.

Other less direct outcomes may also be measurable. Tese include knowledge andattitudes about seat-belt wearing, police ticketing rates and – where crash statisticsare available – deaths and injuries among drivers and passengers o motor vehicles.Knowledge and attitudes are ofen slower to change but can be measured by regular, possibly annual, surveys conducted by interview. As with the observational surveys,these interview surveys should be able to detect di erences between population

groups. t is sometimes possible to use regular omnibus surveys by adding a numbero questions relating to attitudes to seat-belt wearing and to other road sa etymeasures. Tis can be very use ul in providing wider in ormation with whichattitudes to sa ety can be correlated. Police and casualty data can also be use ul, butthey are subject to numerous external in uences and may not accurately re ect thee ect o the campaign.

4.7 Increasing usage: other voluntary measures

Tis section includes consideration o employer regulation and incentive schemes;education and training; and insurance and public incentive schemes.

4.7.1 Emplo er regulation and incentive schemes

Employers have a signi cant role to play in increasing seat-belt usage, especiallyin those countries where legislation and en orcement have not yet been widelyimplemented. Companies and government organizations can help save lives and

injuries o both their employees and contractors by:tting good quality seat-belts to company and contractor vehicles;•

making seat-belt wearing a company regulation both or work-related journeys and•

or sta commuting trips;including seat-belt tting requirements and wearing rules in contracts with road•

transporters;carrying out regular checking o seat-belt usage by sta and contractors;•

providing incentives or compliance and penalties or non-compliance;•

in orming and training sta and contractors on good driving practices, including •

seat-belt use;



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adopting comprehensive road sa ety management systems with road sa ety targets•

or which all sta , especially senior management, are held responsible.

For example, during a number o awareness-raising campaigns in Australia during the s, some private sector organizations voluntarily equipped their eet vehicles with seat-belts. Tis helped raise wearing levels rom almost zero to %, despitethe act that installation o seat-belts in road vehicles was not common practice atthat time ( ). A similar initiative in ndia led by a leading multinational lubricantmanu acturer (see case study) has bene ted not only its own truck operations butalso other companies who can now buy the sa er cab and seat design.

A leading multinational lubricant manu acturer inIndia adopted an integrated sa ety managementsystem to reduce road risks and achieve its goal o eliminating atalities and serious road crashes Theorganization typically had more than 500 vehicleson the road at any one time and these were largelydriven by third-party contractors

Over our years ago most o the trucks had woodencabins and bench seats, which provided poor sa ety

eatures and little occupant protection These cabinswere usually constructed by traditional coach build-ers and not by the original vehicle manu acturer

To improve vehicle sa ety, the organization workedwith vehicle manu acturers to develop a sa e cabinas original equipment This included improvementsin all-round visibility, adjustable tted seat-beltsand adjustable seats or the driver and the driver’sassistant

In three years the organization has voluntarily intro-duced the new seats and tted seat-belts in over2000 trucks, and encourages transport contractorsto purchase trucks with these cabin speci cations asoriginal equipment

To raise seat-belt wearing levels, the organizationhas made seat-belt wearing mandatory as part o the contract agreements Spot checks are carriedout by the organization and penalties are issued ornon-compliance Regulation and compliance monitor-ing have been supported by a major engagementprogramme with transporters and drivers to ensurethat they understand the reasoning behind seat-beltrules and how seat-belts help save lives The organi-zation also recognizes and rewards transporters anddrivers or practising sa e driving

CASE STUDY: Private sector initiative, India




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4.7.2 Education and training

Community education programmes on seat-belts are critical in raising awarenessand understanding o the bene ts o using a seat-belt, encouraging voluntary use andultimately bringing about a sustainable long-term increase in seat-belt wearing rates.

Light Board rom CECF Ad Co Ltd

As with publicity campaigns, the educational process should never be viewed asshort term. Constant rein orcement o the message and targeting o an ever-evolving audience are required in order to continually improve the trend in seat-belt wearing.

Education and public in ormation programmes to encourage seat-belt use can:stimulate and rein orce behavioural change;•

increase public support;•

in uence social norms, making seat-belt use more socially acceptable;•

create a supportive environment or the passage o laws and policies that increase•

seat-belt use.

Tere are a number o approaches that can be used to in orm vehicle owners andoccupants on the need to wear seat-belts, in addition to large national publicitycampaigns. ome o the key options are shown in able . .



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Table 4.9 Key education and training approaches

Actor Approaches

Health personnel ando cials

Provide literature and advice, or instance to new parents on the needto use child restraints, or to patients who have been involved in tra ccrashes, or through health promotion presentations or exhibitions

Manu acturers Provide guidance on the use o sa ety eatures within a vehicle, e gin ormation within the vehicle manual in orming the vehicle owner how toidenti y damage or aults to a seat-belt that indicate that replacement isrequired

Commercial marketing by vehicle manu acturers and retailers, particularlyor child restraints, can play an important role in increasing voluntary seat-

belt use

Road sa ety personnel Have the expertise to increase the knowledge o the whole community,using a wide range o methods They should also consider providingresources and holding special events educating vehicle occupants abouthow to identi y aults and maintain seat-belts

Parents, guardians,teachers via the schoolcurriculum, and themedia

Getting messages across about the bene ts o seat-belt wearing early inli e is obviously desirable This can be particularly bene cial as in ormedchildren can use their knowledge to infuence their parents’ behaviourOnce children have increased their knowledge and adopted good sa epractice, they may well criticize parents or guardians when they exhibit poorsa ety behaviour themselves on the road (e g not astening their seat-beltsbe ore driving o )

While research on the e ectiveness o road sa ety education in changingbehaviour has been inconclusive, what has become clear is thateducational approaches that concentrate only on teaching acts areunlikely to be success ul There has to be a comprehensive packagecontaining several approaches Lesson plans provided or teachers area way o encouraging schools to educate their pupils on the bene ts o seat-belt wearing Appendix 6 shows an example o a lesson plan or usein secondary schools

Stakeholders should also ensure that adequate in ormation is provided toparents on the dangers o using an inappropriate restraint or children

Driver training schools Include in ormation on seat-belt use in their curriculum Instruction shouldinclude in ormation on laws pertaining to seat-belts and child restraints,penalties or non-use and the social and economic bene ts o properlyusing seat-belts and child restraints

A number o case studies are presented below to show examples o educationalapproaches in di erent countries with in ormation about their impact, i available.




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A study o a maternity hospital-based in ant restraintloan scheme in Greece ound that 82% o parentswho were provided with an in ant restraint or sixmonths or a small ee had purchased the next-levelrestraint by the time they returned the loaned one

(23 ) However, another study in Greece showed thatthe target group did not always take up the scheme,particularly in disadvantaged areas where the needwas greatest ( 24 )

CASE STUDY: Education and discount schemes or in ant restraints,Greece

The in ormation leafet shown below, distributed inIndia, concentrates on educating vehicle occupantso the importance o wearing a seat-belt While manyleafets highlight the law regarding wearing, it is justas important to explain why one should wear a seat-belt Here, the vehicleoccupant is in ormed o the substantial orcesinvolved in a 50 km/hcrash due to severedeceleration o thevehicle It explains howa seat-belt can minimizethe injury sustained by avehicle occupant i theyare wearing a seat-belt

It also uses pictures(top right) to dem-onstrate how to it aseat-belt Vehicle occu-pants should push thelap part o the seat-beltdown onto their hips so

that it does not ride onto the abdomen They shouldthen pull the diagonal section up to minimize slack“The diagonal section must stretch rom the anchor-age point over the centre o the occupant’s shoulderavoiding contact with the neck ”

CASE STUDY: Educational leafet, India



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The pictures below show devices that have beenused to educate vehicle occupants on the bene ts o wearing a seat-belt by allowing participants to experi-ence a simulated minor crash (5 km/h) Picturedbelow is the “seat-belt convincer”, used by the JapanAutomobile Federation This has helped to raise seat-belt use rom 62% to 84% in Japan during the lastdecade (Japan Automobile Federation)

Pictured above is a seat-belt sled, a device that canbe used to convince vehicle occupants o the needto wear a seat-belt be ore the introduction o legisla-tion It is an ideal publicity tool or the involvement o celebrities and politicians (FIA Foundation)

CASE STUDY: Educational approaches to increase knowledge o the

bene ts o seat-belt wearing

In Manchester, United Kingdom, a campaign wherepolice targeted schools to promote wearing o seat-belts and child restraints resulted in a rise o 20% inuse o seat-belts A campaign in Ireland in primaryschools raised seat-belt awareness by a scheme thatencouraged children in the rst and second years o school to take the “seat-belt sheri pledge”, by which

they promise to tell all car occupants to buckle up

be ore driving The campaign also included a roadsa ety competition

Alongside ormal education in schools, peer educa-tion is also o ten e ective One study, using childrenas educators o their peers, ound that persuasivearguments given by older children can signi cantlyinfuence the behaviour o younger children ( 25 )

CASE STUDY: Increasing seat-belt and restraint use by children,United Kingdom

4.7.3 Insurance and public incentive schemes

Te motor insurance industry has the opportunity to play a key role in increasing road sa ety within a country. For example, motor insurance companies can encouragethe wearing o seat-belts by making it clear in the wording o their policies that crashcompensation can be reduced signi cantly i it is established that a vehicle occupant was not wearing a seat-belt at the time o a crash. Tis can be applied to private

and company policies. nsurance companies can also promote seat-belt wearing by




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supporting advertising and publicity campaigns. Te e ectiveness o seat-belt clauses will be limited by how well the insurance system is working, the extent o standardcover and compensation provided or victims o crashes, and how well insuranceclients are in ormed about the clause.

Reduced compensation due to non-use o seat-belts

In the United Kingdom, the level o personal injury claims has reduced sincethe recognition by the courts o “contributory negligence” by the injured party’s

ailure to wear a seat-belt In Froom vs Butcher (1975) it was shown that theclaimant’s injuries would have been reduced by 25% had they been wearing aseat-belt, and as such their compensation was reduced by 15% Hitchens vsBerkshire CC (2000) set a precedent by reducing the claimant’s compensationby 50% a ter it was ound that they were not wearing a seat-belt

4.8 How to ensure an appropriate post-crash response

While the primary aim o a seat-belt programme will be to increase seat-belt use, it isalso important or those planning the programme to consider the response providedin the event o a crash (whether or not a seat-belt is worn by the vehicle user). Aquick and appropriate rescue and medical response to the victim o a crash may prevent a atality, or reduce the severity o the injury su ered. Tus, those designing a programme may want to consider both the appropriate rescue and rst-aid responsethat is likely to be given at the scene o the crash and the preparedness o the ormalmedical services that will deal with victims o motor vehicle crashes.

eing involved in a crash can result in li e-threatening injuries, including severe

wounds to the head, chest and limbs that might also lead to unconsciousness andheavy blood loss. Following a crash, skilled rescue rom the vehicle and provisiono rst aid and immediate acute care can make the di erence between the crash victim’s survival or death, and can help reduce the consequences o injuries (see ox

. ). mmediate on-the-scene assistance is o major importance, especially i theemergency services are absent or delayed, and can be encouraged in various ways.

Laws and regulations should be introduced promoting good-quality rst aid,including the ollowing:

a law removing the threat o litigation against those giving rst aid. Many•

countries provide legal immunity rom charges o negligence against a bystanderattempting, in good aith, to help a victim (“good amaritan law”);



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the mandatory inclusion o rst-aid knowledge, skills and a simple understanding •

o scene sa ety in the requirements or obtaining a driving licence or certi cate;a requirement or vehicles to carry a rst-aid kit;•

an incentive or manu acturers or sales people o vehicles to also provide a rst-aid•

kit, or to support the participation o the buyer in a rst-aid training course.

Setting up an emergency medical services (EMS)system may not be easible or many countries, butalternative pre-hospital care arrangements can bedeveloped

The primary prevention o any disease or injury isan overriding priority Many lives can also be saved

ollowing an injury through proper trauma care Thisis especially the case in developing countries, wherethere are high atality rates rom potentially non-li e-threatening injuries

Trauma care, in both pre-hospital and hospital set-tings, requires speedy and appropriate action bytrained personnel, with proper supplies and equip-ment Improving trauma systems has been shown tolower the mortality rate in all treated trauma patients

by between 15% and 20% and to cut the number o preventable deaths by over 50%

Several recent publications provide technical details onhow to improve trauma care Two published by WHO arestrongly recommended: Guidelines or essential traumacare (26 ) and Pre-hospital trauma care systems (27 )

Pre-hospital careThe pre-hospital stage is an important one to targetin e orts to cut the number o road tra c deaths Thecare given will depend on the services that exist

Situations where no ormal EMS exists

A “ ormal” system o EMS is usually one with ambu-lances and trained personnel who work in an agencywith some supervision and with a network o commu-nications Where no ormal EMS exists, governmentsshould make alternative arrangements to providepre-hospital care Ways can be ound to build onexisting in ormal systems and harness communityresources, such as training members o the publicin basic rst aid, scene sa ety and simple rescuetechniques Setting up ormal EMS systems in urbanareas and along major interurban roadways shouldalso be explored Cost should be a consideration,given the high cost o these systems

Strengthening existing intervention s stems: EMSs stems and rescueMany EMS systems could be strengthened in anumber o ways, or example by establishing a regu-latory agency to promote minimum standards orthe delivery o prompt, high-quality and equitablepre-hospital care; by streamlining communicationbetween sites where calls are received (such as alarmcentres) and the sites o ambulance dispatch, as wellas between di erent ambulance services; and bykeeping good records on people cared or by the EMS,so as to monitor and improve the quality o care

Essential trauma careImprovements in trauma care need not necessarilyinvolve high-cost, high-technology equipment Muchcan be accomplished in an a ordable and sustain-able way through better planning and organization

The essential trauma care services and theresources required or them can be promoted inseveral ways, including through needs assessmentso trauma care requirements; training in trauma care,provided in appropriate educational settings; qualityimprovement programmes that consider the entiretrauma acility setting; and the inspection o trauma

acilities ( 27 )

RehabilitationMany o those who survive injury ace disabilities

that limit their physical unctions Many o theseconsequences are avoidable and can be reducedby improving rehabilitation services Rehabilitationservices are an essential element o trauma care,and can be improved by conducting more in-depthneeds assessments or injury-related rehabilita-tion, by strengthening the capabilities o nationalrehabilitation programmes, and by integrating therecommendations o World Health Assembly Reso-lution WHA58 23 and the recommendations onrehabilitation in the Guidelines or essential traumacare (26 ) into a country’s health policy

BOX 4 8:Ensuring that the emergency medical services are prepared




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4.8.1 Seat-belts and injuries

eat-belts and child restraints may produce injuries. Although a seat-belt holds thebody in place on the seat, it cannot prevent the head rom being thrown aroundduring a collision. Emergency personnel should be aware that a belted occupantcould have sustained a neck injury and manage them accordingly.

Te place where the seat-belt makes contact with the body during a collision mayalso result in minor injuries such as bruising (“the seat-belt sign”) or more serious problems such as broken ribs. However, it is highly probable that the injuries thatthe belted occupant would have sustained had they been unbelted would have beenmuch more severe.

Children who are restrained in the rear o a vehicle with two-point lap belts can,under certain circumstances, sustain abdominal or lumbar spine injuries during acollisions – the so called “seat-belt syndrome”. Although most new vehicles are nowequipped with three-point lap and diagonal seat-belts in all seating positions to prevent this problem, it is important that emergency personnel recognize incidents where occupants have used lap belts (mechanisms o injury).

4.8.2 Seat-belt removal

Following a collision it is important to remove the seat-belt rom around a casualty assoon as possible. y doing so, rescuers will help to protect the casualty rom receiving secondary injuries and to prepare the casualty or removal. Prompt removal o theseat-belt will help:

eliminate restrictions to breathing or circulation;•

protect victims rom urther injury due to accidental activation o seat-belt•

pretensioners;allow sa e movement o the casualty during cutting or spreading operations in the•

vicinity o seat-belt anchor points.

n addition, by removing the seat-belt, emergency personnel are reducing constraints placed on the casualty, which in turn enables them to remove casualties quickly i

their condition deteriorates.Tere are however times when the seat-belt must not be removed until the casualty issupported. Tese include where the casualty is suspended by the seat-belt in incidents where the vehicle has come to rest on its roo or its side (see related notes).



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Vehicle on its side

At incidents where the casualty is on the side o the vehicle that is nearest tothe ground suspension by seat-belts is less likely to occur, and there ore inthese circumstances seat-belts can be removed or cut Where the casualty ison the upper side o the vehicle and suspended by the seat-belt then speci cactions must be considered Once the vehicle has been stabilized and it issa e to do so casualty carers should enter the vehicle to treat and support thecasualty The easiest method to e ect a sa e rescue rom this type o incidentis to old down the vehicles roo It is essential when carrying out this operationthat the upper seat-belt anchor points are taken into consideration, and thatthey are not a ected by cutting or spreading operations

Vehicle on its roo

Where a casualty is suspended by the seat-belt in an overturned vehicle, theconsideration here is to create as much space within the vehicle by opening orremoving doors and winding ront seatbacks up By doing so a greater amounto space will be created inside the vehicle to allow as many carers and rescu-ers as possible around the casualty to allow support and then a controlledlower ollowing release or cutting o the seat-belt




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BOX 4 9:Seat-belt removal

As soon as possible arrangements should be made to release orremove the seat-belt

The easiest method is to unclip the seat-belt rom the anchor pointPersons assisting with this must ensure that the casualty is not beingsupported by the seat-belt They must also ensure that they do not putthemselves at risk by placing themselves within the deployment patho any airbags that are present

Once the seat-belt has been unclipped, totally remove it rom thecasualty and place it out o the way to prevent trip/snagging hazards

Where there is a need to cut the seat belt, again ensure that thecasualty is not being supported by the seat belt

The easiest method is to cut the belt in two places, in the centre o the diagonal and on the lap belt portion By doing so this will preventunnecessary pulling and tugging o the belt against the casualty as itis removed

First support the casualty by hand and cut the diagonal portion o the beltas shown It is best to use a sa ety seat-belt cutter were possible

Once the diagonal is cut, the lap portion o the seat-belt should now becut, again using a sa ety seat-belt cutter

Once both cuts are complete totally remove remaining belt por-tions rom the casualty and place out o the way to prevent trip/snagging hazards

Note: On all occasions where seat-belts have been removed this in ormation must be passed to both medical per-sonnel, to assist with identi ying mechanisms o injury, and police personnel, to con rm adherence to local laws



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Summary

Tis module provides an overview o the steps necessary to design an e ective programme aimed at increasing seat-belt use, in turn decreasing serious injuries and

atalities amongst drivers and passengers. As stressed throughout the module, ane ective programme depends on a combined approach using legislation, standards,education and en orcement.

Appropriate legislation is an important step to increasing seat-belt use. An initialassessment o the current legislative situation will help decide whether a new lawis needed or i a revision to an existing law would be su cient. t is important to

identi y how, when and where the new law will be implemented. Legislation shouldbe promoted by the highest levels o government to ensure that it has the support o en orcement agencies and a proper legitimacy among the public.

tandards or seat-belts should be developed to ensure access to quality sa etyequipment. tandards – o design and materials used – should be set so as to give vehicle occupants a high level o protection in the event o a crash.

Te act remains that any standard adopted to increase the sa ety o vehicleoccupants is better than none. However, in order to provide consistency and acoordinated approach to raising the standard o seat-belts, it is recommended thatcountries adopt the uni orm technical prescriptions outlined by the World Forum

or Harmonization o Vehicle Regulations.

A system should also be implemented that ensures regular independent testing,assessing wear and damage o seat-belts and their components using pass and ailcriteria. Guidance should be provided to both vehicle owners and vehicle inspectorson assessing wear and damage o seat-belts.

o aid the process o encouraging vehicle occupants to wear seat-belts, organizationsshould be convinced o the need to play a proactive role in the installation o seat-belts in eet vehicles. Tis will result in an improvement in road sa ety overall whilstachieving health and sa ety objectives.

oth voluntary and mandatory measures can be used to increase compliance witha seat-belt law. ndeed, continuous and air en orcement o the law is essential orraising rates to a signi cant level. Tis calls or a strong commitment rom both thegovernment and the en orcement agency. Existing en orcement agencies should beevaluated to see i their capacities need to be increased. A plan or penalizing motor-ists who break the law on seat-belt use should be devised. Penalties can take the ormo warnings, nes or the suspension o licences.

ogether with legislation and en orcement, a well-designed marketing and publicitycampaign is essential or the success o a seat-belt use programme. o meet these

objectives, a good marketing or advertising agency may need to be taken on to




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create an e ective communication campaign. Communication should be aimed atmotorists not using seat-belts, as well as at a secondary audience with the potential toin uence non-users. Te messages should be simple, consistent and memorable, andappropriate to the social and cultural standards o a particular country.

Tere is an important role or public education, school education and peer educationamong young people. Educational programmes, combined with other activities, canhelp shif behavioural norms towards making seat-belt use more acceptable.

When designing a seat-belt use programme, practitioners should consider the post-crash response to crash injuries. Tis involves addressing the appropriatenesso rst-aid services, and examining the capacity or provision o pre-hospital care,essential trauma care and rehabilitation services to assist crash victims.

able . summarizes the main steps in the process o implementing a seat-belt programme.

Table 4.10 Checklist or designing and implementing a seat-belt programme

Step Components

Implementingoverall seat-beltwearing programme

Assessment o seat-belt use•

Identi cation o problem•

Selection o objectives•

Selection o corresponding activities•

Developinglegislation, creatinga penalty system,and developingor improvingstandards

Consideration o institutional or cultural constraints•

Selection o objectives•

Dra ting o legislation•

Creating a penalty system•

Approval o legislation•

Implementation o legislation•

Developing anen orcementstrategy

Assessment o capacity to en orce•

Increasing policy capacity i necessary•

Training police in en orcement•

Increasing thevoluntary use o seat-belts by thepublic

Develop and implement a publicity campaign:•

Set the objectives, targets and per ormance indicators or the campaign–Select an agency or the campaign–Create campaign messages and select the creative concept that will–reach the target audienceConsider how to best incorporate and work with the media–

Map out campaign stages in relation to seat-belt legislation and– strengthened en orcement by the policeCarry out and evaluate the campaign–

Consider developing and encouraging other voluntary approaches, including:•

Engaging employers in increasing seat-belt usage among sta and–contractors through employee regulation and incentive schemesImplementing public education and training programmes to reach diverse–segments o the public, such as children and new driversEngaging the insurance sector in proactive schemes to encourage seat-–belt usage

Ensuringappropriateresponse at anda ter scene o thecrash

Encourage appropriate rst aid to victims o crashes through legal•

ramework and delivery o rst-aid education programmesConsider the pre-hospital care, essential trauma care and rehabilitation•

services that are required and existing capacity to respond to these needsTrain and equip rescuers to ensure the prompt and sa e removal o victims•

unable to remove their seat-belts



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Re erences

1. roughton J. Restraint use by car occupants, 19 2–19 9. Research Report . Crowthorne, UnitedKingdom, RL Ltd, .

2. Lonero L, Clinton K, leet DA. ehavior change interventions in road sa ety. n: Gielen AC,leet DA, DiClemente R, eds. Injury and violence prevention: behavior change theories, methods

and applications. an Francisco, Cali ornia, Jossey- ass, : – .3. Promoting seat belt use. E C Fact heet number , April (http://www.etsc.be/

documents/Fact_ heet_ eat_ elt_Use_ .pd , accessed ovember ). Updated data provided by l'Observatoire national interministériel de sécurité routière, .

4. Seat belt campaign toolkit . London, F A Foundation, May (http://www. a oundation.org/news/archive/ /Pages/ eatbeltcampaigntoolkit.aspx, accessed October ).

5. Pinder M. Changes made to seat belt law.Bahama Journal , March .6. Agreement concerning the adoption o uni orm technical prescriptions or wheeled vehicles, equipment

and parts which can be ftted and/or be used on wheeled vehicles and the conditions or reciprocal recognition o approvals granted on the basis o these prescriptions. Revision . Geneva, United

ations Economic Commission or Europe, nland ransport Committee, (http://www.unece.org/trans/main/wp /wp regs.html, accessed ovember ).

7. UNECE Regulation 14, Revision 2: sa ety-belt anchorages. Geneva, United ations, (www.unece.org/trans/main/wp /wp regs – .html, accessed ovember ).

8. UNECE Regulation 16, Revision 4: sa ety-belts and restraint systems.Geneva, United ations, (www.unece.org/trans/main/wp /wp regs – .html, accessed ovember ).

9. UNECE Regulation 44, Revision 1: restraining devices or child occupants o power driven vehicles

(child restraint system). Geneva, United ations, (www.unece.org/trans/main/wp / wp regs – .html, accessed ovember ).

10. Recommendations or anchoring o seat belt assemblies.Appendix ZD o A / Z : .11. Compliance cost assessment: seat belts in coaches and minibuses. London, United Kingdom,

Department or ransport, .12. ylund P-O, jörnstig U.Use o seat-belts in cars with di erent seat-belt reminder systems: a study o

injured car drivers. AAAM th Annual Con erence, – eptember .13. Williams AF et al. uckle up now! An en orcement program to achieve high belt use. Journal o

Sa ety Research. , ( ).14. Primary en orcement saves lives: the case or upgrading secondary sa ety belt laws. ational Highway

ra c a ety Administration, (http://www.nhtsa.dot.gov/people/injury/en orce/

PrimaryEn orcement/index.htm, accessed ovember ).15. Van Rooyen P. Principles o social marketing: the Saatchi worldwide experience.Marketing ra c

a ety: V th World Congress o the nternational Road a ety Organization, – October ,Cape own, outh A rica.

16. ilveira AJ.Seat-belt use in Buenos Aires, Argentina: a 14-year-old struggle.Luchemos por la Vida.Paper presented at the nternational Con erence on ra c a ety on Four Continents, Warsaw,October .

17. Polish seat belt campaign.Krajowa Rada ezpieczenstwa Rucha Drogwego, .18. Donovan RJ, Jalleh G, Henley . E ective road sa ety advertising . edlands, Australia, Road

Accident Prevention Research Unit, .




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19. Seat belt campaign. Global Road a ety Partnership and akhalin Energy nvestment CompanyLtd, (http://www.grsproadsa ety.org/?pageid= &projectid= # , accessed ovember

).20. arawneh M , Al- albissi AH, arawneh M. Te e ectiveness on seat belt use in Jordan o a

public education campaign. Journal o ra c Medicine, , ( – ): – .21. Department or ransport, London, United Kingdom (www.df.gov.uk, accessed ovember

).22. Milne PW. Fitting and wearing o seat belts in Australia: the history o a success ul countermeasure.

Canberra, Australia, Australian Government Publishing ervice, .23. Kedikoglou et al. A maternity hospital-based in ant car-restraint loan scheme: public

health and economic evaluation o an intervention or the reduction o road tra c injuries.Scandinavian Journal o Public Health, , ( ): – .

24. Dedoukou X et al. Evaluation o an in ant car restraints loan scheme in Athens, Greece. n:

Con erence proceedings. What works in child injury prevention: bridging the gap between research and practice. intra, Portugal, – October, .25. Morrongiello , radley MDM. ibling power: in uence o older siblings’ persuasive appeals on

younger siblings’ judgements about risk taking behaviours. Injury Prevention, , : – .26. Mock C et al.Guidelines or essential trauma care. Geneva, World Health Organization, .27. asser et al. Pre-hospital trauma care systems.Geneva, World Health Organization, .



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55How to evaluatethe programme



5.1 Planning the evaluation 1455 1 1 Aims o evaluation 145 1 2 Types o evaluation 14

5.2 Choosing the evaluation methods 1515 2 1 Study types or ormative and process evaluations 1515 2 2 Study types or impact and outcome evaluations 1515 2 3 Choosing the per ormance indicators 1565 2 4 Conducting an economic evaluation o a programme 1575 2 5 Determining sample size 158

5.3 Dissemination and eedback 1595 3 1 Checklist or evaluation process 1595 3 2 Using evaluation results to eed back into new planning cycle 159

Summary

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Monitoring and evaluation o any programme or intervention is vitalto determine whether it works, to help re ne programme delivery and to

provide evidence or continuing support o the programme. Evaluation will not only provide eedback on the e ectiveness o a programme but will also help to determine whether the programme is appropriate or the target population, whether thereare any problems with its implementation and support and whether there are anyongoing concerns that need to be resolved as the programme is implemented.

Tis module describes the process o developing and conducting an evaluation o aseat-belt programme. t is divided into three key sections:

. Planning the evaluation.Tis important initial section describes how to de nethe aims o an evaluation, and details the various orms evaluation may take (process,impact and outcome).

. Choosing the evaluation methods. Once the type o evaluation has beendetermined, there are di erent methods that can be applied to carry out anevaluation. Tis section describes the di erent study types possible, explaining the advantages and disadvantages o each type o method. t outlines the types o per ormance indicators that can be used to measure the success o a programme. Tissection also brie y describes how to conduct an economic evaluation, and providesguidance on calculating sample size.

. Dissemination and eedback.Tis section describes how to eed the result o

an evaluation back into the planning and implementation stages, and ways that theresults o an evaluation can be shared with di erent interested parties.

5.1 Planning the evaluation

Te process o designing and implementing a seat-belt or child restraint programme was covered in Module . Work carried out prior to implementation should ensurethat the programme is clearly de ned and that it is implemented in a consistent andstandardized way. t is ar easier to evaluate the impact o a complete, well-plannedand executed programme than one that is implemented in an inconsistent way.

t is essential that the evaluation ramework is developed and implemented alongsidethe proposed programme. Tus, this work would be carried out by the working group as they develop the action plan or the programme (see Module ). For most

orms o evaluation, baseline measures need to be collectedbe ore the intervention is put in place so that change in such measures over time may be gauged. t is there oreimportant that the evaluation ramework is well established early on.



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Te type o evaluation to be conducted will depend on a number o actors. Teseinclude the aims o the evaluation itsel and the objectives o the programme being evaluated. Te type o methodology chosen may also depend on resource constraints.

5.1.1 Aims o evaluation

Establishing the aims o the evaluation will help to determine how best to carryout the evaluation. Te evaluation may have one or more aims. For example, anevaluation o seat-belt legislation and an increased en orcement programme may primarily be aimed at determining whether seat-belt wearing rates have gone up asa result o the programme. econdary aims may include determining whether theen orcement has increased, whether training o police is e ective and whether the programme is acceptable to the stakeholders. Te evaluation in this case needs to bemulti aceted.

Te breadth o an evaluation will always be limited by the resources available, and a well-designed simple evaluation can be as power ul as a more complex one.

the objective is to increase the provision o seat-belts tted in vehicles, stakeholdersmay wish to assess:

the number and type o vehicles with seat-belts installed;•

the number and type o vehicle manu acturers tting seat-belts as standard;•

the number and type o imported vehicles sold in the country with seat-belts•

installed;seat-belt sales or retrospective tting;•

the number and type o vehicles retrospectively tted at approved test centres;•

seat-belt standards and legislation (implemented and en orced).•

evaluation o a speci c discipline is required, or example publicity, then questionsmust be asked that are speci c to that element o the campaign. For instance, i aseat-belt cinema advertising campaign has been implemented aimed at vehicle usersaged – years, it is important that evaluation o success or this element is notclouded by data regarding all vehicle occupants. Tere ore stakeholders may wish toassess using the ollowing data:

baseline wearing rates or – -year-olds;•

the number o – -year-olds attending the cinema where advertising is shown;•

surveys o – -year-olds’ opinions and awareness prior to viewing advertising;•

surveys o – -year-olds’ opinions and awareness afer viewing advertising;•

national and local wearing rates or – -year-olds;•

crash and injury severity data or – -year-olds.•




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5.1.2 T pes o evaluation

Evaluation may take several orms, and one or more may be appropriate, depending on the aims o the speci c programme to be evaluated ().

Process evaluation

Rather than measuring change in outcomes, process evaluation examines whether the programme was carried out as planned. Tis involves creating a list o indicators thatneed to be measured, depending on the aims o the programme. Te results will helpto identi y the strengths and weaknesses o the programme, and where improvementsmay be made.

For example, in a media campaign designed to increase voluntary use o seat-beltsand child restraints, a process evaluation may ask these sorts o questions:Have the campaign products (posters, billboards, radio and television spots) been•

pre-tested?How ofen were the campaign advertisements run?•

How many people saw them?•

Was the target group being reached?•

Are high-quality child restraints available in local shops?•

the intervention involves en orcement o seat-belt legislation:s there noticeable en orcement by police?•

Are the police supportive o the campaign?•

s the penalty su cient to change behaviour?•

Are people able to circumvent the process ( or example, using bribery)?•

Process evaluations are “ ormative”; that is, the enquiries carried out are designed to provide in ormation to guide programme improvement ( ). For example, it may beconsidered important to determine whether the television advertisements shown as part o a seat-belt programme are appropriate – do they adequately address the issue,do they give the right in ormation about how to choose child restraints?

Impact assessment

An impact assessment will determine whether the advertisements have broughtabout a change. Te impact, or programme e ect, re ers to whether the programmehas made an impact on the target population ( ). For example, i the seat-belt programme involved airing television advertisements on seat-belt use, the impactassessment might examine whether people who had seen the advertisements believedthat there was a good chance that they would be ned by the police i they did not wear a seat-belt.




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A new campaign to raise awareness o the need towear seat-belts in the rear o cars was launched bythe Department or Transport in July 1998 Researchamong the target audience had indicated that mostwere not aware that an unbelted rear seat passengercould kill the driver in the event o a crash The cam-paign ocused on this act ( 3 )

Monthly tracking research monitored the impact o the campaign in terms o awareness, understandingand attitudes to particular road sa ety behaviours

Observational, evidential and accident data werealso collected to give a longer-term measure o cam-paign impact

Independent survey work commissioned by thedepartment be ore and a ter the campaign indicatedsigni cant attitudinal changes For example, therewas a substantial increase in the numbers recogniz-ing that, in a crash, a rear seat passenger not wearinga seat-belt could injure or kill the driver or ront seatpassenger Research among 2000 adults showed

signi cant shi ts in awareness o the seat-belt wear-ing message Recognition that an unbelted rear seatpassenger might kill the driver in the event o a crashrose rom 33% to 53% among 16–24-year-olds

The week-long campaign ran in July 1998 and wase ective not only in raising awareness but also ina ecting seat-belt wearing behaviour It is almostcertain that many drivers who took note o the adver-tising were asking passengers to belt up

Observational research is carried out each April andOctober by the Transport Research Laboratory InApril 1998, three months be ore the campaign, theadult wearing rate in the rear was 48% In Octoberit was 54% The advertising campaign has been runover occasional week-long bursts since then Theincreasing understanding o what can happen hasbeen accompanied by an improving trend in seat-beltwearing rates In October 2006 the rate was 65%,

ollowing a new campaign aimed at young men (seealso United Kingdom case study in section 4 6 7)

CASE STUDY: Evaluation o rear seat-belt campaign, United Kingdom

Outcome evaluation

An outcome evaluation measures outcomes to see i the programme was success ul.Are more people now wearing seat-belts than be ore? Have deaths and seriousinjuries been reduced? Are more children restrained in child restraints suitable ortheir age and size? Measuring a change in outcomes is probably the most common

orm o evaluation as it provides in ormation as to whether the programme orintervention has actually made a di erence ( ).

Te case study on the China eat- elt ntervention Project describes the evaluationo the seat-belt campaign in Guangzhou, China. Tis evaluation included a processevaluation assessing the changes in police en orcement practice, and an outcomeevaluation in terms o the e ect on seat-belt wearing rates. t also estimated thecost–e ectiveness o the campaign.




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In China, injuries are the leading cause o death romage 1 to 44 years, accounting or approximately 750000 deaths and 3 5 million hospitalizations eachyear Much o the injury-related mortality and morbid-ity is due to road tra c injury, perhaps expectedly,given that motor vehicle production has tripled sincethe early 1990s In the large urban centres such asBeijing, Shanghai and Guangzhou, where the burdeno road tra c injuries is growing rapidly, there isan urgent need to implement proven road sa etyinterventions In the absence o widespread imple-mentation o road sa ety interventions, the epidemico road tra c injuries will worsen The China Seat-Belt Intervention Project was an initiative proposedby the representative o WHO in China and developedby the George Institute or International Health Itinvolved cooperation between the Chinese Govern-ment, international organizations and industry It waso cially launched in Guangzhou in mid-2005 In thisone province, almost 10 000 road tra c crashestook place during 2004, resulting in 1800 deathsand almost 12 000 people injuries

In 1993, the Ministry o Public Security in Chinainstituted a regulation requiring all vehicles less than6 m in length to have seat-belts tted or the rontseats Despite the availability o seat-belts in almostall cars (excluding trucks) in China and laws on theuse o seat-belts, their use has not reached levelsachieved in countries such as Australia, where seat-belt use is as high as 90%

Aims

The main purpose was to implement a compre-hensive intervention over 12 months ocused onincreasing seat-belt use in Guangzhou, with the ol-

lowing speci c aims:

to increase the rate o correct seat-belt use by•

20%;to estimate the cost–e ectiveness o the•

intervention;to build capacity in road tra c injury prevention in•

Guangzhou

Methods

The evaluation o the intervention was undertakenby adopting a comparison group pre-test/post-testdesign Two sites were selected, one that received

the intervention (Guangzhou City) and another thatacted as a comparison site (Nanning City) Prior tothe implementation o the intervention, extensivebaseline (pre-test) measures o the key outcomeswere undertaken These measures were repeated 12months post-intervention (October 2006)

An economic evaluation was undertaken to determinethe cost–e ectiveness o the intervention The reason

or conducting an economic analysis was to ensurethat injury prevention resources were being allocated

to programmes that represented value or money

Status and results

In order to explore the barriers to seat-belt useamongst drivers and ront seat passengers, anumber o ocus groups were hosted in GuangzhouCity A survey into seat-belt availability and seat-beltquality was conducted in November 2004

A success ul launch o the intervention was held on25 April 2005 at Times Square in Guangzhou CityRepresentatives rom the Ministry o Public Security,the Ministry o Health and provincial government, aswell as representatives rom WHO and the project

under, BP China, attended the launch

From 20 to 24 June 2005, 50 senior tra c policeo cers received skills-based training and were edu-cated on strategies or en orcement by Mr Ray Shuey,the ormer Assistant Commissioner o Police in Aus-tralia Training or all police o cers was conductedacross all the branches o Guangzhou Tra c Com-mand and Control Centre (TCCC) between Augustand October 2005, with 1125 tra c police (82 6%)in Guangzhou trained in enhanced en orcement prac-tices targeting the en orcement o seat-belt use

Throughout the month o September 2005, the Divi-sion or Sa ety and Education o TCCC conducted acomprehensive educational programme or taxi com-panies in Guangzhou, aiming to raise the prevalenceo seat-belt use among taxi drivers

Five intensive law en orcement activities aimed atpromoting seat-belt use, linked with a social mar-keting campaign, were conducted between October2005 and August 2006 Each tra c police branchin Guangzhou established two checkpoints withinits precincts Target locations included locations

CASE STUDY: Seat-Belt Intervention Project, China

Continues…




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with high crash risk, the train station, the airport andtollgates Tra c police o cers who had attended thetrain-the-trainer course were appointed to oversee theen orcement Normal routine en orcement was stillapplied when speci c campaigns were not in opera-tion During the study period, several approachesincluded in the training were implemented by TCCC toencourage tra c police o cers to continue en orcingthe use o seat-belts and penalizing in ringers

As described above, comprehensive social market-ing campaigns linked with intensive en orcementwere implemented Related

in ormation was published onthe tra c management website; stickers and brochureswere distributed among driv-ers; posters were displayed ina number o parking lots andtaxi company premises; busadvertisements delivering thekey message “Seat-belts savelives” were displayed on 15buses along three bus routesthat ran through the city centre;the intervention advertisingwas released in two majornewspapers, eatured onGuangzhou CATV six to seventimes per day and broadcaston Guangzhou Radio tra icchannel (FM 106 1) 18 timesper day The highly popular tel-evision commercial or the intervention, developed bycollaborators and the Chinese Export CommoditiesFair Advertising Co Ltd, won a bronze prize at the13th Guangdong Advertising Collection in 2006

The post-intervention observations were collectedin late 2006 and statistical analysis o results wascompleted in early 2007 The results showed that

ollowing the 12-month intervention period, the preva-lence o seat-belt use increased signi cantly, rom aprevalence o 50% (range 30–62%) to a prevalenceo 62% (range 60–67%) in the intervention city Incontrast, the prevalence o seat-belt use declined,signi icantly, in the comparison city; an overall

di erence between the increased prevalence in the

intervention city and decline in the comparison cityo 18% Importantly, the prevalence o seat-belt useincreased signi cantly ( P < 0 01) rom pre- to post-intervention in the intervention city across all actors,namely seat-belt use by male or emale drivers, bothdrivers and ront seat passengers, and across roadtypes and vehicle types The greatest increase in theprevalence o seat-belt use was among drivers andpassengers o taxis in the intervention city The prev-alence o seat-belt use among taxi drivers increasedby 21% ( P < 0 01) ( rom pre-test 30%, range 10–58%,to post-test 51%, range 45–60%) In contrast, the

prevalence o seat-belt use sig-

ni cantly declined ( P < 0 01) inthe comparison city over theobservational period acrossthe same actors

Based on the increased preva-lence o seat-belt use observedas part o the intervention, theestimated total number o disability-adjusted li e years(DALYs) saved as a result o the intervention was 530Taking account o the cost o

implementing the intervention(US$ 221 500), along with theassociated cost savings, theincremental cost–e ective-ness ratio o the interventioncompared with no enhancedprogramme to increase the

prevalence o seat-belt use was 3246 Chinese yuanper DALY saved (or the equivalent o US$ 418 perDALY saved)

The intervention provided the government with theopportunity to build capacity in road sa ety and, at

the same time, provided in ormation on the opportu-nity to target nancial resources in order to reducethe burden o road tra c injury Importantly, thestudy provided outcomes such as changes to policeen orcement practice and comprehensive roadsa ety communication strategies that are a legacy o the project and will be invaluable to both central andprovincial-level governments who are responsible orroad sa ety in China ( 5 )





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5.2 Choosing the evaluation methods

Te methods used or each type o evaluation will vary. oth qualitative andquantitative methods can be used within the design o an evaluation. Qualitativemethods may be employed or the ormative or process evaluations, or example

ocus groups and use o short-answer or open-ended questionnaires ( ).

mpact and outcome evaluations may be carried out using a variety o quantitativemethods. Using an experimental or quasi-experimental design to demonstrate achange (or not) is the most power ul programme evaluation or detecting changes inoutcome. Te type o methods used will depend on the aim o and the budget or the

evaluation.

5.2.1 Stud t pes or ormative and process evaluations

Formative evaluation is ofen in the orm o qualitative research, which tends toinvolve detailed verbal descriptions o characteristics, cases and settings to explainreasons underlying various behavioural patterns. peci c techniques includeusing ocus groups, in-depth interviews or surveys with short answers or open-ended questions ( , 8). For example, a question in a ormative evaluation o amedia campaign aimed at increasing seat-belt use may be whether the television

advertisements address the question. Focus groups may be set up to determine whether the audience believes that the message rom the television advertisements isappropriate. Feedback will urther enhance the development o the advertisement.

Researchers in Ghana evaluated the e ectivenesso televised road sa ety messages on speeding andalcohol-impaired driving (9 ). Focus groups were con-ducted with 50 commercial drivers and addressed

coverage, clarity and appropriateness o messages,including suggestions or improvements The adver-tisements reached and were understood by most

o the target audience, although some participantswere unclear on the behaviour that the advertise-ments were urging viewers to take Opportunities

or strengthening the messages included using

other media, increasing the number o languagesused and stressing the change in behaviour beingrecommended

CASE STUDY: Evaluation o televised road sa ety messages, Ghana

5.2.2 Stud t pes or impact and outcome evaluations

Tere is a well-de ned hierarchy o study designs or examining the e ectiveness o interventions. Tese range rom randomized controlled trials, which provide a highlevel o evidence, to uncontrolled be ore–afer studies, which provide very weak

evidence about the e ectiveness o an intervention.




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Randomized controlled trial

Te gold standard o evaluation, the randomized controlled trial (RC ), will providethe highest-quality level o evidence o whether an intervention or programme issuccess ul. For the RC , individuals (or groups o individuals, or example a schoolor village, in a variant o the RC known as a cluster randomized trial) are randomlyallocated to either receive, or not receive, the programme. As participants (or groupso participants) are randomly assigned to one group or another, other actors thatmay in uence the outcome – measured and unmeasured – are more likely to bebalanced between the intervention and non-intervention groups. However, althoughRC designs should always be considered when evaluating the e ectiveness o anintervention, they do require signi cant resources and may be di cult to conduct

with a limited budget. Tere may also be ethical considerations in randomizing anintervention with known bene ts (that is, in denying an e ective intervention tothose participants who will be in the non-intervention group).

t is important to note that there is no need to conduct an RC on the e ectivenesso seat-belts themselves as part o the seat-belt programme. Tere is su cientevidence rom a number o studies that clearly demonstrates that seat-belts aree ective at reducing the injuries and atalities that result during motor vehiclecrashes (see Module ).

Examples o randomized controlled trials

Goodson, Buller & Goodson ( 10 ) carried out an RCT o prenatal sa ety educa-tion in two hospitals in the United States Reported use o child sa ety seatswas 96% or the intervention group and 78% or the control group

Stuy ( 11 ) studied children aged 2–6 years and parents at childcare centreso ered educational activities In the intervention group children observedwearing seat-belts rose rom 54% be ore to 75% a ter For the control groupthe rise in seat-belt wearing rates was rom 20% to 30%

Quasi-experimental designs

Quasi-experimental study designs, while not as rigorous as randomized trials, i wellconducted, may also be used to establish the e ectiveness o an intervention. uchdesigns may also involve a “treatment” and a “control” group, but individuals orcommunities are not randomized into these groups.




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Controlled be ore–a er study

Te controlled be ore–afer study is ofen the most practical design or programmeevaluation. Randomization is not always easible, or example where some areas havealready adopted an intervention. Te controlled be ore–afer study design involvesobserving the outcome o interest ( or example seat-belt use rates) be ore and aferthe programme, in both the people who receive the programme and those in acontrol group. Te control group should be as similar as possible to the programmegroup and any important di erences between the groups need to be taken intoaccount. Having a control group means that trends that may have been occurring inthe population aside rom what was happening due to the programme are taken intoaccount ( ox . ).

A school-based intervention was developed in 1999to increase seat-belt use among amilies living alongthe Texas-Mexico border, where child use o seat-belts had been ound to be low The Socorro SeatbeltProgram sought to increase seat-belt use by changingperceived norms within the community, i e makingthe non-use o seat-belts less socially acceptableChildren in primary schools were shown reasons why

amily members should wear seat-belts, and reasonswhy they might not do so Related activities includedposter competitions and role model stories, and seat-belt newsletters were distributed to amilies Parentswere invited to join their children in a second posterand slogan competition

Two adjacent communities served as the interven-tion and control sites There were ve schools in

the intervention community and six in the controlcommunity The two communities were similar interms o demographic characteristics

Pre-intervention seat-belt use was observed at eachprimary school during a 13-day period Post-interven-tion assessments were conducted exactly one yearlater In the intervention community, seat-belt useamong children increased rom 47% to 57%, whilst inthe control community seat-belt use among childrenshowed a non-signi cant decline rom 50% to 47%Whilst there was no signi cant change in drivers’seat-belt wearing arriving at the intervention schools,at the control schools drivers’ seat-belt wearingdeclined signi cantly rom 90% to 83% ( 12 )

BOX 5 1:Evaluation using a controlled be ore–a ter study

Be ore–a er study (no control group)Te be ore–afer study without a control group is ofen used to evaluate theimpact o a programme, but provides the weakest evidence or the e ectiveness o a programme. Tis design involves measuring the outcome o interest be ore and aferthe programme has been run. Tis study design is simple and may be conductedrelatively cheaply, as all that is needed is a sampling rame and research assistants toconduct observations at various sites. However, without a control group the scienti cmerit o these study types is relatively limited, as it is ofen di cult to attribute withany certainty the change in outcome to the introduction o the programme.




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In 1972 it became compulsory or all vehicle occu-pants to wear seat-belts in Queensland, AustraliaQueensland Transport implemented public educationcampaigns over several years, and in 1997 the Fatal4 campaign was developed in conjunction with theQueensland Police Service Research conducted byQueensland Transport in August/September 2000showed that 10% o people admitted to driving with-out a seat-belt The most requently cited reason was“being on a short trip” The campaign aimed to dispelpopular myths:

Seat-belts are only necessary on long journeys•

Seat-belts cause injuries•

It is not necessary to wear a seat-belt in the rear•

The campaign during 1998 to 2000 aimed toencourage motorists and passengers to buckle upby alerting them that police will en orce the wearingo seat-belts and reminding them o the penalties o non-compliance The campaign included televisionand radio advertising, billboard and taxi messages,and a brochure aimed at visitors to the Olympicsin 2000 Research showed that support or thestatement “Since the ad I have made more o ane ort to wear my seat-belt” increased signi cantly

rom 46% in April 1999 to 58% in August 2000 In2001, research showed that only 5% o motoristsadmitted to driving without wearing a seat-belt O respondents, 64% claimed that they had seen someor all o the billboard messages, and 50% o motor-ists believed that the billboard messages stronglyencouraged them to belt up ( 13 ).

CASE STUDY: Be ore–a ter study (no control group) to evaluate aseat-belt campaign, Queensland, Australia

Interrupted time series design

t is possible to assess the e ect o a programme by using multiple measures o theoutcome o interest be ore and afer the programme. Tere are a number o di erent variations on this design, some involving control groups. tudies that have used thesedesigns generally use routinely collected measures, such as death rates, as multiplemeasures are required or appropriate analysis. Tis study design is, however,subject to time-related challenges to its validity, given the possibility that other

actors occurring simultaneously to the programme actually led to the observede ect. tatistical analysis o such data can take into account any such secular trends,meaning that it is possible to establish whether the intervention or programme wasresponsible or the change in outcome.

able . summarizes the characteristics and advantages and disadvantages o thestudy types discussed in this section. Further detail about study types is available inre erences and . Tere is also a use ul online glossary o research terms at http:// www.cochrane.org/resources/glossary.htm.




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Table 5.1 Study types and their advantages and disadvantages

Formative,processevaluation?

Impact,outcomeevaluation?

Advantages, disadvantages

Qualitative

Focus groups/in-depth interviews

Formative•

Process•

Outcome• Can provide in ormation on why•

intervention may or may not have workedCheap•

Sample (participants) is not random•

Results are not generalizable•

Quantitative

Randomizedcontrolled trial

Impact•

Outcome•

Most rigorous evidence•

Expensive•

Randomization not always easible•

Controlled be ore–a ter study

Impact•

Outcome•

Most practical design•

Must have comparable control group•

Be ore–a ter study(no control group)

Impact•

Outcome•

Cheap•

Low level o evidence•

Interrupted timeseries design

Impact•

Outcome•

Practical design i su cient numbers•

o events and accurate surveillancesystems in place

A systematic review ( 16 ) identi ed 16 studies exam-ining the e ects o educational campaigns aimedat increasing the use o sa ety seats and seat-belts

or children A variety o approaches were used, withall studies including an element o pro essionalcounselling to encourage use o restraints (seat-belts etc ), supported by a range o media Someprogrammes included rewards or coercion such as

nes to encourage compliance There is evidencethat the campaigns led to an increase in observed

restraint use, although this may not be sustainedin the long term This conclusion is supported byGrossman and Garcia ( 17 ), who report that the mag-nitude o positive e ects rom such programmesdiminishes substantially one or more months a terthe intervention More intensive programmes appear

to produce more positive results There is someindication that programmes may be less e ective

or older children

Two urther reviews ( 18, 19 ) conclude that educa-tion alone has a modest e ect in increasing use o child restraints This can be considerably strength-ened among younger children where appropriaterestraints are provided through a loan, low-cost rentalor giveaway programme, alongside education and

guidance in their proper use Incentive and educationprogrammes that reward parents or correctly usingchild restraints or reward children or using themhave been shown to be e ective in increasing childrestraint use in the short term (1–4 months) ( 19 )

BOX 5 2:E ectiveness o programmes promoting use o child restraints




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5.2.3 Choosing the per ormance indicators

Per ormance indicators (or outcome measures) are a measure o how success ulthe programme has been. Choice o per ormance indicators will be determinedby the aims o the evaluation, the study type used, the resources available and, to acertain extent, the requirements o the unding agency. For instance, government

unding agencies may require certain in ormation to ensure support or increaseden orcement or or urther roll-out o a programme.

Injury and death outcomes

Te e ectiveness o seat-belts in reducing crash-related injury and death has been well documented in many studies (see Module ) and there may be no need toreplicate these ndings in a large-scale (and possibly expensive) piece o experimentalresearch. Although much o this e ectiveness research has been conducted in high-income countries (predominantly the United tates) there is no reason to believethat seat-belts would be less e ective in preventing death and injury in low-incomesettings.

it is necessary to calculate death and injury rates it may be possible to use routinelycollected data as the basis or these calculations. However, the e ciency with whichsuch rates can be calculated depends on the accuracy o local surveillance. thereis a uni orm capture, coding and reporting system already set up in hospitals orhealth departments there may be aggregated data available on crash-related injury.Otherwise this may need to be abstracted rom local data sources. imilarly, motor vehicle crash and death data may be routinely collected rom police or transportauthorities.

As quality may be variable, completeness and accuracy o these data sources shouldbe care ully checked be ore use.

Seat-belt wearing rates

Possibly the most use ul per ormance indicator to use in the evaluation o a seat-belt wearing campaign is the proportion o drivers and passengers wearing seat-belts.Observations o vehicle occupants may be made at a number o sites be ore and afera programme to document whether seat-belt wearing rates have changed.

Calculating rates

Comparing changes in absolute numbers in injury and death outcomes, or in driversand passengers wearing seat-belts, be ore and afer a programme is not use ul, asabsolute numbers may change due to an increase or decrease in the numbers o vehicles, registered or otherwise. t is there ore important that rates be calculated.Denominators may include number o vehicles, registered vehicles or kilometres

travelled. For example, or injury outcomes a rate may be number o injuries per




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licensed drivers, or number o injuries per km driven. For seat-belt use, theappropriate rate would be the proportion o belted occupants over total occupantsobserved. ote that it is pre erable to use a population denominator ( or example per population) rather than the number o vehicles as a denominator. Tisis because the rapidly increasing use o motor vehicles in many countries may distortthe results o an evaluation, i this latter measure is used.

Module includes a detailed section on how to measure seat-belt wearing rates.

5.2.4 Conducting an economic evaluation o a programme

t may also be necessary to conduct an economic evaluation to demonstrate value

or money and possible cost savings or government by investing in prevention.Economic evaluation addresses the question o whether one intervention representsa better use o resources than another. n other words, does spending $X on programme A represent a better investment than $X on programme ? o addressthis question, it is apparent that a comparison o two or more options is needed(sometimes this comparison is with a “do nothing” or “status quo” alternative).

Economic evaluation is based on the comparison o alternatives in terms o theircosts and consequences( ). Te term “consequences” is used here to representan outcome o value. Tere are various orms o economic evaluation that can beconducted, each di ering in terms o scope, i.e. the range o variables included inthe analysis. mportantly, each orm o economic evaluation typically entails a set o starting assumptions; recognition o these is necessary or the policy-maker to makeappropriate use o the evidence rom such studies.

A common element across all orms o economic evaluation is that they involvemeasuring costs. Costs usually comprise, at least in part, the direct programmecosts – the resources that are used to run the programme ( or example, equipment,sta , consumables). However, in principle, other costs may also be relevant, such asthose incurred by patients, carers and the wider community. Furthermore, there aredownstream costs and cost savings that may enter into consideration; or example, a programme may result in reduced hospitalizations and these savings in resources maybe deemed relevant. Te type o costs selected generally depends on the perspectivetaken in the evaluation and the nature o the resource allocation problem being addressed.

Methods used in economic evaluation

Te most common orm o economic evaluation iscost–e ectiveness analysis (CEA). Tis entails placing the total cost o programmes alongside a de nedoutcome to produce a cost–e ectiveness ratio ( or example, cost per li e saved, cost per li e year saved or cost per case prevented). Te assumption in CEA is that the

objectives o interventions being compared are adequately captured in the measure o




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outcome used( ). One modi cation to conventional cost–e ectiveness analysis iscost–utility analysis, which is based on an outcome measure, the quality-adjusted li e year (QALY). Tis incorporates changes in survival and quality o li e and therebyenables a wider set o interventions to be legitimately compared than would be possible with CEA. Te case study rom China in section . . shows the results o acost–e ectiveness study.

Another orm o economic evaluation iscost–bene t analysis, which seeks toevaluate interventions in terms o total costs and total bene ts, both dimensionsbeing valued in monetary terms ( or example dollars). Tere ore i bene ts aregreater than costs, the decision would be to und the programme. Valuation o healthbene ts in this way can be challenging, but one approach would be to elicit rom

bene ciaries o programmes their maximum willingness to pay or these bene ts(i.e. i they had to pay or it in a hypothetical market place). Te idea behind thisapproach is to derive a valuation or an intervention akin to the way in whichconsumers value goods and services in markets ( ).

Cost–bene t analyses o seat-belt wearing show that the bene ts clearly outweighthe costs, with bene t–cost ratios o between and ( 3).

Choosing the appropriate type o economic analysis or the needs o the particular programme will depend on resources available (both economic and humanresources) and the aims o the evaluation.

5.2.5 Determining sample size

For all quantitative study types it is important to have su ciently large numbers inthe study to be sure that i an e ect exists it is detectable. Te rarer the event, thegreater the sample size needs to be in order to detect a di erence. erious injuries

rom motor vehicle crashes are relatively rare events and a study using serious injuryor death as an outcome would involve a large sample size. Measuring seat-belt wearing rates requires a smaller number o participants.

Factors that must be taken into consideration in determining the sample size are

the expected size o the e ect to be detected, variability in the measures and the prevalence o the variable o interest. For a cluster randomized trial, sample sizecalculations will also take the size o the cluster and correlation within clusters intoaccount. For urther in ormation on sample size calculations or cluster randomizedtrials see re erence .

ample size calculators are reely available on the nternet, but it is wise to consult astatistician regarding such estimates, particularly where cluster randomized trials orrandom or strati ed samples are necessary.




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For quantitative study designs data will require statistical analysis. For more adviceon how to go about this re er to re erence , or see the relevant lectures in the basicmethods and injury sections at http://www.pitt.edu/~super .

5.3 Dissemination and eedback

Once an evaluation is complete it is important to provide eedback to thestakeholders involved in the programme. Dissemination o the results will help to

garner urther support or the programme i it is success ul, and help others gainsupport or the introduction o similar programmes. Publicity rom disseminationactivities may also increase the impact o the programme. the programme has notbeen success ul it is important to share this with others so that weaknesses or relevantissues are considered in other similar interventions, including whether or not tointroduce such interventions.

Dissemination may involve presenting the results at public meetings, using the mediato publicize the outcomes o the programme or publishing reports and papers inthe scienti c literature. Dissemination, translation and di usion activities are ofen planned in advance so as to increase the chances or nationwide adoption o the

e ective interventions ( ).

5.3.1 Checklist or evaluation process

tart evaluation process at the beginning o programme implementation.•

Determine aim o evaluation and develop evaluation ramework.•

Clearly de ne target population, place and time.•

Develop and test instruments or data collection, ensuring consistency in training •

and measurement.Collect and analyse data.•

Write and disseminate evaluation report, eeding back into various aspects o •

programme.

5.3.2 Using evaluation results to eed back into new planning c cle

Consider whether the evaluation demonstrated any tangible bene ts – should the programme be continued, or does it require disbanding or modi cation? Can theexisting programme be improved on the basis o the evaluation? Have there been anyunexpected side e ects o the programme?

Te results o the evaluation should be ed back into the planning cycle and the

appropriate modi cations to the programme made be ore it is urther expanded.




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Summary

Evaluation should be seen as an integral component o any seat-belt programme.An evaluation needs to be determined at the beginning o a programmedevelopment, such that the plan or data collection or this purpose is built into project implementation. As well as providing in ormation on the e ectiveness o a programme, evaluation will help identi y i there are any problems in running a programme.

Determining the aims o the evaluation will help to decide how best to carry outthe evaluation. Tere are a number o di erent methods that can be used to evaluate

a seat-belt programme. Each method has various advantages and disadvantages,and the choice o which to use will depend on the aims o the programme and theresources available.

t is important that the results o the evaluation are shared with the appropriate parties, and that they are used in the planning o the programme. Dissemination,translation and di usion o e ective interventions will help increase the chances ornationwide adoption.

Re erences

1. Tompson J, McClintock HO. Demonstrating your program’s worth: a primer on evaluation or programs to prevent unintentional injury. Atlanta, Centers or Disease Control and Prevention,

ational Center or njury Prevention and Control, .2. Rossi PH et al. Evaluation: a systematic approach. Cali ornia, age Publications, .3. H K! Always wear a seat belt: rear seat belt campaign. Tink! Road a ety Campaign, United

Kingdom Department or ransport, (http://www.thinkroadsa ety.gov.uk/campaigns/seatbelts/rear.htm, accessed ovember ).

4. Zaza et al. Methods or conducting systematic reviews o the evidence o e ectiveness andeconomic e ciency o interventions to reduce injuries to motor vehicle occupants. American Journal o Preventive Medicine, , ( ): – .

5. tevenson M et al. Reducing the burden o road tra c injury: translating high-income countryinterventions to middle- and low-income countries. Injury Prevention, in press .

6. Tompson J. tudy methods or understanding injury behavior. n: Gielen A, leet DA,DiClemente R, eds. Injury and violence prevention: behavioral science theories, methods and applications. an Francisco, Jossey- ass, .

7. ritten . Qualitative research: qualitative interviews in medical research. British Medical Journal, , : – .

8. Kitzinger J. Qualitative research: introducing ocus groups. British Medical Journal, ,: – .




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9. lantari J et al. An evaluation o the e ectiveness o televised road sa ety messages in Ghana. International Journal o Injury Control and Sa ety Promotion, , : – .

10. Goodson J, uller C, Goodson W. Prenatal child sa ety education.Obstetrics and Gynaecology,, : – .

11. Dowswell , owner E. ocial deprivation and the prevention o unintentional injury inchildhood: a systematic review. Health Education Research, , : – .

12. Cohn LD et al. A program to increase seat belt use along the exas-Mexico border.American Journal o Public Health, , : – .

13. Seat belts public education campaign.Queensland ransport, (http://www.roadsa ety.qld.gov.au/qt/L A in o.ns /Re erenceLookup/ eatbeltsPubEd.pd /$ le/ eatbeltsPubEd.pd ,accessed ovember ).

14. Woodward M. Epidemiology: study design and data analysis,nd ed. oca Raton, Chapman andHall CRC, .

15. Rothman KJ, Greenland . Modern epidemiology,nd ed. Hagerstown, Maryland, Lippincott-Raven, .

16. owner E et al.What works in preventing unintentional injuries in children and adolescents? Anupdated systematic review.London, Health Development Agency, .

17. Grossman G, Garcia D. E ectiveness o health promotion programs to increase motor vehicleoccupant restraint use among young children.American Journal o Preventive Medicine, ,

( ): – .18. Di Guiseppi C, Roberts . ndividual-level injury prevention strategies in the clinical setting.

Future Child , , ( ): – .19. Dinh-Zarr et al. Reviews o evidence regarding interventions to increase the use o sa ety belts.

American Journal o Preventive Medicine, , ( ): – .

20. Drummond MF et al. Methods or the economic evaluation o health care programmes.Ox ord,Ox ord University Press, .

21. an- orres et al, eds.WHO guide to cost-e ectiveness analysis.Geneva, World HealthOrganization, .

22. Miller R. Te e ectiveness review trials o Hercules and some economic estimates or thestables. American Journal o Preventive Medicine, , ( ): – .

23. Elvik R, Vaa , eds.Te handbook o road sa ety measures.Elsevier, .24. Kerry M, land JM. tatistics notes: sample size in cluster randomisation. British Medical

Journal, , : .25. ogolow E, leet DA, aul J. Dissemination, implementation and widespread use o injury

prevention interventions. n: Doll L et al., eds. Handbook o injury and violence prevention. ewYork, pringer, .



162



AAppendices



Appendix 1. United Nations Economic Commission or Europe(UNECE) seat-belt questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . 165

Appendix 2. Sample seat-belt wearing observation orm . . . . . 174

Appendix 3. Example seat-belt wearing law . . . . . . . . . . . . . . . . 175

Appendix 4. Inspecting seat-belts and their components . . . . . . 177

Appendix 5. Roadblock or checkpoint management . . . . . . . . . . 185

Appendix 6. Sample lesson plan or teaching seat-belt sa etyin secondary school . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189




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Appendix 1.

United Nations Economic Commission orEurope (UNECE) seat-belt questionnaire

1

UNITEDNATIONS E

Economic and Social

Council

Distr.GENERAL

TRANS/WP.1/2004/7/Rev.121 July 2004

Original: English

ECONOMIC COMMISSION FOR EUROPE

INLAND TRANSPORT COMMITTEE

Working Party on Road Traffic Safety

(Forty-fifth session, 27–30 September 2004, agenda item 5(e))

REVISION OF THE CONSOLIDATED RESOLUTIONS R.E.1 AND R.E.2

Increasing seatbelt usage

REVISED QUESTIONNAIRE ON SEATBELTS

AND CHILD RESTRAINTS POLICIES AND PROGRAMMES

A. Introduction

Motor vehicle crashes represent a major cause of fatality and injury, both in highlymotorized, as well as developing countries. This is an issue that is a major publichealth problem, predicted to become even more of a global challenge over the nextseveral decades. The use of safety belts and child restraint systems are the mosteffective means of reducing fatalities and serious injuries to vehicle occupants.Increasing the use of safety belts is also seen as the most effective defensive stepindividuals can take to reduce serious injury from the reckless behaviour of, forexample, impaired drunk and drugged motorists and drivers displaying aggressivebehaviour on the roadways.

This questionnaire was developed by the Special Work Group on Increasing SafetyBelt Use set up during the 43rd session (22–25 September 2003) of the UNECEWorking Party on Road Traffic Safety. Please refer to working documentTRANS/WP.1/2003/15, Use of Seat Belts , for further information on the purposeand work mandate of this group.

B. Explanation




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S e a

t i n Front seat Back seat

3

Children under 12with child restraints* Children under 12with child restraints*

D r i v e r

P a s s e n g e r

F F C R S

R W C R S

B o o s t e r

P a s s e n g e r s

F F C R S

R W C R S

B o o s t e r

U s a g e

%

D a t e

c o l l e c t e d

__/__/__ __/__/__ __/__/__ __/__/__ __/__/__

* Child restraints (CRS): covers forward-facing (FFCRS) and rear-facing child restraints(RWCRS) and booster seats.

5. How do you collect information about seatbelt and child restraint wearing?Check all that apply:

Seatbelts: Child restraints:

Observation Observation

Crash data Crash data

Self-reported by occupants Self-reported by occupantsOpinion/telephone surveys Opinion/telephone surveys

Other, please state: Other, please state:

…………………………… ……………………………….

E. Legislation

6. In your country, are vehicles legally required to have seatbelts fitted/installed?

Front Rear Centre rear

Y/N Year Y/N Year Y/N Year

Passenger carsNon-commercial vans,Multi-purpose vehicles (MPVs) 1

Cars

Sports utility vehicles (SUVs) 2

Commercial vehicles (trucks, goodscarriers, commercial vans)

Public buses

Tourist buses/motor coaches

Minibuses

Buses

School buses

1 MPVs or non-commercial vans (for the US and Canada) are also called people carriers.They provide space for more vehicle occupants than in a normal passenger car (e.g. 7 seats)and provide more luggage capacity .2 SUVs: e.g. 4 x 4, pick-up trucks.



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7. Do you have an international or domestic technical standard for seatbeltinstallation/performance?

Yes

No

If yes , please state: …………………………………………………….........

…………………………………………………………………………………..

8a. Is your seatbelt legislation:

Federal/National

State/Provincial

Extra comments: …………………………………..............................….....

………………………………………………………………………………….

8b . Do you have legislation making seatbelt use mandatory?

Front 1 Rear 2

Y/N Year Y/N Year

In any circumstance

In town only

Cars

Outside town only

In any circumstance

In town only

Commercialvehicles

Outside town only

In any circumstance

In town only

Buses

Outside town only

In any circumstance

In town only

Public buses

Outside town only

In any circumstance

In town only

Touristbuses / minibuses

Outside town onlyIn any circumstance

In town only

Schoolbuses

Outside town only

1 For commercial vehicles and buses, driver and co-driver, if applicable.2 For buses, it concerns passengers.

9a. Are there exemptions for mandatory use?

Yes

No

4




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5

If yes , please state:

Medical reasonsSize (too small or too big)

Taxi driver in service

Police

Fire vehicles

Ambulances

Mail services in town

Vehicles carrying out deliveries

Other, please state:…………………………………………………………………………

…………………………………………………………………………

9b. When there are medical reasons, does an official medical certificate have tobe present for checking?

Yes (What is the maximum duration: ….……………………………)

No

9c. Does this certificate have a symbol recognised at an international level?

Yes

No 10a. Do you have legislation making child restraint use mandatory?

National/federal law State/provinc ial law Front Rear Date law enacted

Yes

No

10b . Please provide a breakdown of legal requirements by age bands and specificchild restraint type*:

Seating posit ion (if specifi ed)Age band (e.g. 0–2) Type of restrain t Front Rear

* Child restraint: forward-facing (FFCRS) or rear-facing (RWCRS) child restraint or booster seat.



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Would you like to add any other observations? (e.g. is a particular childrestraint not allowed in a particular seating position?)

…………………………………………………………………………………

…………………………………………………………………………………

11. Are drivers in buses/taxis obliged to carry child restraints?

Yes

No

If yes , please state:..….……………………………………………......

…………………………………………………………………………………..

F. Enforcement

12. What are the sanctions for violations of seatbelt/child restraint laws?

Seatbelts Child restraints

DriverMonetary fines – amount:

Passenger

Penalty points against driver’s license, ifapplicable. Specify number/total points: _ _ / _ _ _ _ / _ _

Other: please state:

………………………………………..

………………………………………..

13. Are the police involved in any seatbelt/child restraint activities other thanenforcing seatbelt/child restraint laws?

Yes

No

If yes, briefly describe:

………………………………………………………………………………

………………………………………………………………………………

G. Education14. Do you have a road safety education programme in schools?

Yes

No

15 . At what age does the education programme start?

…………………………………………………………………………………..

16a . Does the education programme include information about seatbelts?

Yes

No

6




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If yes , what type of information is included?

……………………………………………………………………………………………………………………………………………………………………

16b. Does the education programme include information about child restraints?

Yes

No

If yes , what type of information is included?

………………………………………………………………………………

………………………………………………………………………………

17. Does the wider national education programme for the rest of the populationinclude information for parents/carers, e.g. grandparents, about correct childrestraint use?

Yes

No

18. In the last 12 months, has your Government advertised seatbelt messagesusing the following media? Please tick all that apply:

Seatbelts: Child restraints:

TV campaigns TV campaigns

Radio campaigns Radio campaigns

Cinema advertising Cinema advertising

Outdoor/posters/billboards Outdoor/posters/billboards

Leaflets Leaflets

Print e.g. newspapers, magazines Print e.g. newspapers, magazines

Internet, new media Internet, new media

Public relations Public relations

Other, please describe: Other, please describe:

…………………………… …………………………..

…………………………… …………………………..19. Do you use shock tactics in advertising?

Yes

No

If yes , how does the impact compare with more subtle tactics?

…………………………………………………………………………………..

…………………………………………………………………………………..

H. Evaluation and research

7



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20. Do you routinely measure the effectiveness of your seatbelt programme?

YesNo

If yes , how do you determine the impact of:

a) individual interventions (e.g. a new law enacted, a new TVadvertisement)

………………………………………………………………………………..

………………………………………………………………………………..

b) the entire seatbelt strategy (e.g. seatbelt wearing rates, reduction ofcasualty rates, awareness of seatbelt messages, publicity, etc.)

…………………………………………………………………………………..…………………………………………………………………………………..

21. Have you carried out research into the characteristics of people who don’t usesafety restraints?

Yes

No

If yes , how did you use the information?

…………………………………………………………………………………

…………………………………………………………………………………

22. Do you enlist the support of third parties to help focus on and improve seatbeltuse among some low use groups, e.g. young men 16–24?

Yes

No

If yes , please give examples:

…………………………………………………………………………………..

…………………………………………………………………………………..

23. Does your seatbelt programme offer your stakeholders incentives to help (e.g.grants, additional police equipment, etc.) to increase seatbelt/child restraint

use:Seatbelts Child restraints

Enforcement bodies Enforcement bodies

Other governmental bodies Other governmental bodies

Vehicle users Vehicle users

Other, please state: Other, please state:

…………………………… …………………………..

…………………………… …………………………..

advertisement)




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9

……………………………………………………………………………………………………………………………………………………………………

If yes , please give examples for child restraints :

…………………………………………………………………………………..…

…………………………………………………………………………………..…

Name of person responding to this survey:…………………………………………

Title: ………..………………………………………………………………………………

Service and/or administration:…………………………………………………………

…………………………………………………………………………………..……………

May we contact you if we have questions about any of your answers?

Yes No

E-mail:…………………………………………

Telephone number:……………………… Fax number:……………………………

If yes , please give examples for seatbelts :



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Appendix 2.

Sample seat-belt wearing observation orm

Source: Broughton J Restraint use by car occupants 1982–1989. Research Report 289 Crowthorne, United Kingdom, TRL Ltd 1990




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Appendix 3.

Example seat-belt wearing law

Model Law

Standard (Primar ) Sa et Belt Model Law

National Committee on Uni orm Tra fc Laws and Ordinances

June 16, 1997

Purpose: Te purpose o this legislation is to reduce injuries and atalities on thestreets, roads and highways by requiring all drivers and all passengers to wear sa etybelts meeting applicable ederal motor vehicle sa ety standards while riding in motor vehicles and by authorizing primary en orcement.

Section 1: Title

Tis act may be cited as the [ tate’s] a ety elt Use Act.

Section 2: Defnitions

As used in this act:

(a) “Motor vehicle” means any motor vehicle having a gross vehicle weight o , pounds or less that is required to be equipped with sa ety belts by Federal Motor Vehicle a ety Primary o. . Passenger cars are required to have belts i built aferDecember , . Light trucks and multi-purpose vehicles are required to havesa ety belts i built afer December , .

(b) “Driver” means a person who drives or is in actual physical control o a motor vehicle.(c) “ a ety belt” means any strap, webbing, or similar device designed to secure a person in a motor vehicle including all necessary buckles and other asteners, and allhardware designed or installing such sa ety belt assembly in a motor vehicle.

Section 3: Application

Tis act shall apply to drivers and all occupants o motor vehicles on the streets,roads, and highways o this tate.



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176

Section 4: Operation o motor vehicles with sa et belts

(a) Each driver o a motor vehicle in this tate shall have a sa ety belt meeting applicable ederal motor vehicle sa ety standards properly astened about his or herbody at all times when operating a motor vehicle.

[(b) Alternate – Te driver o a motor vehicle in this tate shall not operate a motor vehicle unless the driver secures or causes to be secured in a properly adjusted and

astened sa ety belt or child restraint system meeting applicable ederal motor vehiclesa ety standards all passengers and secures any passenger or younger in the rearseat, unless all available rear seats are in use by other passengers or younger.]

[(b) Alternate – Te driver o a motor vehicle in this tate shall not operate a

motor vehicle unless every occupant is secured in a properly adjusted and astenedsa ety belt or child restraint system meeting applicable ederal motor vehicle sa etystandards and consistent with the [ tate’s] child restraint use law.]

(c) Every occupant o a motor vehicle in this tate shall have a sa ety belt meeting applicable ederal motor vehicle sa ety standards properly astened about his or herbody at all times when the vehicle is in operation.

Section 5: Exemptions

(a) Te provisions o sections ( ) (c) shall not apply to children covered by [cite to

the tate’s child restraint use act or law].(b) Te provisions o section ( ) shall not apply to persons with a physicallydisabling condition whose physical disability would prevent appropriate restraintin sa ety belts, provided, however, such condition is duly certi ed by a physician who shall state the nature o the condition, as well as the reason such restraint isinappropriate.

(c) Te provisions o this law shall not apply to passenger cars built prior toDecember , and possessing no sa ety belts.

(d) Te provisions o this law shall not apply to passenger vehicles which are notrequired to be equipped with sa ety belts under ederal law.

Section 6: Penalties

A person who violates section ( ) (a), (b), or (c) o this act shall be punished by a neo not less than $ . nor more than $ . , [and court costs] and [ or tates with points systems] demerit points.

Source: ational Highways ra c a ety Administration, U A(http://www.nhtsa.dot.gov/people/injury/en orce/PrimaryEn orcement/images/

PrimaryEn orcement.pd , accessed ovember ).




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Appendix 4.

Inspecting seat-belts and their components( rom United Kingdom Vehicle Inspectorate inspection manual)



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Appendix 4

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Source: Vehicle Inspectorate The MOT inspection

manual: car and light commercial vehicle testing.3rd edition. Norwich, United Kingdom, HMSO, 1996




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Appendix 5.

Roadblock or checkpoint management

ntercepting moving vehicles in the ow o tra c or random or speci c en orcementrequires the utmost attention to planning and risk assessment.

Te primary consideration when setting up a checkpoint or roadblock is the sa ety o police o cers, suspected drivers and other road users. o site should be in operation without a designated sa ety o cer who has the responsibility o ensuring overallsa ety (this person may have other roles as well). Even where only two or three o cers

are operating, one o cer should be the sa ety o cer. Managing checkpoints includes:

1. Choosing a sa e location

electing a sa e location includes considering:locating the site where approaching drivers have su cient time and visibility to•

adjust their driving in order to sa ely negotiate the checkpoint. in doubt, chooseanother location;sa ety actors or o cers when setting up and dismantling the site. Persistent bad•

weather can render a site impractical or unsa e;moving the site to multiple locations during the course o the work period to•

maximize the visible police presence;sun glare or drivers approaching the site (the sun will change its position during •

the course o the day); visibility or motorists, which is o particular concern at dusk and dawn, so extra•

precautions should be taken i the operation is taking place over one o those periods;locating night-time operations where there is e ective illumination and providing •

additional lighting or high visibility;control o vehicles moving into the site as well as those vehicles passing it;•

the avoidance o unnecessary tra c congestion. Judgement as to what constitutes•

unreasonable congestion is subjective but, as a general rule, i the end o the tra ccannot be seen in the distance, it is time to suspend testing operations and allow itto ow until the end can be seen;the use o natural barriers where tra c calming is achieved, e.g. tollgates.•

2. Slowing tra fc sa el

On a two- or three-lane carriageway, it is best to slow the tra c down using a unnelormation o delineation cones, a police checkpoint sign and a merge sign so that

the selection and interception o vehicles can be done rom a line o slow-moving

tra c rather than a high-speed one. A police car with ashing lights acts as a visible



Appendix 5

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warning to approaching motorists and more importantly provides a sa ety corridoror o cers to interview o ending drivers. the unnel method (see gure) is chosen,

be aware o the tra c volume both at the time o establishment and what could beexpected later. arrowing to one lane will automatically create congestion so thosenot selected must be moved through quickly.

Figure 1 Funnel method o slowing tra c ( = sa ety cones)

En orcement Sa ety Corridor Check Point

Merge sign & policecheckpoint sign

Police car fashing lights

Centerline

Tis method may create advance notice that en orcement is being undertaken.uspected drivers may take a number o evasive actions e.g. change positions with a

passenger, abandon their vehicle, attempt to drive through the checkpoint, turn lefor right be ore the interception point, or carry out a U-turn. For these reasons it isimportant to have an intercept vehicle strategically placed prior to the interception point to pick up drivers attempting to evade the checkpoint or roadblock.

A team approach to the management o checkpoints is particularly bene cial whereonly two or three police o cers are operating, or example, at a set o tra c lights where there is a sa e interception point just through the intersection. One o cermay stand at the tra c lights and identi y drivers who stop at the red light. Teycan be directed by that o cer to his colleague(s) undertaking the check. Tis systemalso operates success ully at tollgates. t provides a mix o visible en orcement and

warnings to motorists.




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3. Using equipment to ensure sa et

a ety is paramount. Te right equipment must be used properly to ensure the sa etyo tra c police o cers and road users at all times.

All members on site should wear re ective vests or jackets both day and night.•

All members must be in police uni orm.•

Use police vehicles as tra c protection.•

Use marked police vehicles with lights ashing to maximize visibility (be•

conscious o the battery li e with lights ashing and engine o ). there are any o cial observers, they should not be permitted on site without•

re ective vests.Equipment should include illuminated torches tted with a red cone to provide a•

contrasting colour.Delineation o the site should be with strobe lighting or red sa ety cones.•

Consider i any o the surrounding equipment could be used as a sa ety barrier.•

Consider natural barriers or natural interception points, e.g. tollgates, service•

stations, parking centres, entries and exits.Ensure there are su cient police numbers or a sa e, e ective operation.•

Ensure the operations command centre is aware o the site location.•

Consider photographic or video evidence.•

4. Contingenc planning

Ensure there is a process or dealing with:no licence•

no registration•

stolen vehicles•

intoxicated drivers•

re usal to stop at interception point.•

While the majority o drivers will be compliant and not present any problems, thereare others who may be argumentative, or who try to avoid being stopped – e.g.nervous drink drivers or criminals.

5. Getting the message across

Te most important aspect o this method o policing is to provide a deterrent toboth those being checked and drivers who pass by unchecked. Drivers passing thesite should be made aware o the purpose o the checkpoint by means o either a variable message sign or large xed sign advising “ eat-belt en orcement”. t is highlyimportant to have a message clearly visible.

this is not done, other drivers may assume it is an ordinary police security check orother tra c checkpoint and no change to their attitude will occur.



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6. Processing o enders quickl

drivers are to be processed it should be undertaken with minimum delay tothe driver. Observations should be clearly stated to the driver and corroborationrom ellow o cers sought i there is denial. Evidence should be recorded without

argument or bargaining. Police must always be courteous and polite and maintain ahigh degree o skill and pro essionalism.

7. Meeting statistical requirements

Te ollowing in ormation should be recorded:number o motor vehicles that passed the site (estimated by taking a number o •

sample counts during the operation and multiplying the numbers or the time atthe location);number o o enders processed;•

number o police persons involved;•

number o hours worked at the location.•




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Appendix 6.

Sample lesson plan or teaching seat-beltsa ety in secondary school

In-car sa ety

Lesson plan

opic o lesson: n-car sa ety (use o sa ety devices, such as seat-belts and airbags).

Length o lesson: minutes ( minutes o video).

arget audience: – -year-olds.

Curriculum subject: Personal, social and health education, citizenship.

Equipment required: elevision and video player.

Resources required: crash test video; seat-belt sample (a belt can be used i a seat-beltsample is unobtainable); relevant lea ets such as that highlighted in Module o the manual; other lea ets outlining the current legal situation or seat-belt wearing;“ / ths o a second” text sheet (included at end o lesson plan); national and local publicity material, such as posters, key rings etc.

ote: ome educational resources may contain project work or teaching ideas thatcan be incorporated into the lesson.

Aims and objectives o the lesson

to raise pupils awareness o the dangers o irresponsible occupant behaviour;•

to highlight the consequences o non-use o in-car sa ety devices;•

to encourage the use o in-car sa ety devices;•

to highlight the bene ts o using in-car sa ety devices.•

Introduction: what is the role o a sa et device in a vehicle?

Vehicle sa ety eatures all into two categories; “primary” and “secondary” sa etyeatures. Primary sa ety eatures aim to prevent an accident taking place, e.g. good

brakes, tyres. econdary sa ety eatures aim to prevent or minimize injury to a vehicleoccupant once the accident has occurred, e.g. side impact protection systems, airbags.



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eat-belts are asecondary sa ety device with a number o objectives. Tese include: preventing ejection rom the vehicle in an impact;•

reducing the risk o contact with the interior o the vehicle or reducing the speed•

o such impacts; providing a distributed orce to the wearer to give the necessary support in an•

accident, restraining the vehicle occupant be ore guiding them back into their seat.

Te American College o Emergency Physicians () suggests that seat-belts are themost e ective means o reducing deaths and serious injuries in tra c accidents. Teyalso calculate that % o all vehicle occupants ejected rom a vehicle in an accidentdie as a result.Seat-belts provide the greatest protection against ejection in a crash.

Airbags are an active, high-energy device commonly designed to act as asupplementary measure to the per ormance o a seat-belt. an occupant isunrestrained, or the vehicle has an airbag installed but no seat-belt, it is possible thatthe occupant may come into contact with the airbag be ore it has ully in ated. Tisis also the case or people who need to sit closer to the steering wheel as a result o their size. Airbags deploy at approximately 00 km/h. I the vehicle occupantcomes into contact with the airbag be ore it is ully infated, there is a real risk o the vehicle occupant sustaining serious injuries.

Note. Tere are three collisions to every crash where occupants are unrestrained.Te rst collision involves the vehicle and another object (e.g. car, barrier or orm o street urniture). Te second collision occurs between the unbelted occupant andthe vehicle interior. Finally, the third collision occurs when the internal organs o the body hit against the chest wall or the skeletal structure. Although there are many

actors to consider, it is the second collision that is most responsible or injuries, andcan be reduced signi cantly by the use o seat-belts.

n an accident travelling at km/h, a vehicle occupant’s body weight increasessigni cantly (approximately times). n such circumstances the weight o theoccupant would be similar to that o an elephant. A seat-belt is designed to withstandsuch a orce.

Bod o lesson

Use lea et containing current seat-belt wearing legislation to outline the audience’s•

legal responsibility. no legislation exists continue to next point.Discuss the e ects o non-seat-belt use in a collision to outline the audience’s•

moral responsibility.

ring two volunteers to the ront o the room and seat them one directly behind theother (about metre apart). Enact the scenario o the driver travelling at km/h wearing a seat-belt, and the back seat passenger in the same vehicle not wearing aseat-belt. Demonstrate that there are three movements or seat-belt wearers in an




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accident: rst, they move orward, and are then restrained by the seat-belt; second,they move back into their seat; third, they ride down into the seat.

For occupants not wearing a seat-belt, there is one movement; orward until theycome into contact with the vehicle interior or other occupants or are thrown romthe vehicle.

Rein orce that it is calculated that % o all vehicle occupants ejected rom a vehiclein an accident die as a result.Seat-belts provide the greatest protection againstejection in a crash.

Demonstrate the movements o the two occupants:Driver/ ront occupant:• moves orward, is restrained, is brought back into seat.

Rear occupant:•

moves orward, hits the back o the driver’s seat, the two headscollide, rear occupant crushes the driver between their seat and their seat-belt.Likelihood:• driver/ ront occupant is dead.

Discuss the moral responsibility o the rear occupant to wear their seat-belt.

how video o sample crash tests that clearly demonstrate the use o seat-belts andairbags.

alk audience through the test. Explain that research has shown thatthe simpleact o buckling a seat-belt can improve an occupant’s chance o surviving a potentially atal crash by % to 7 %.

Rein orce the point that although airbags can be an e ective restraint, reducing theseverity o injury to occupants involved in an accident, they are designed to act asa supplementary measure to the per ormance o a seat-belt and should not be usedindividually.

Demonstrate correct tting o seat-belt with the use o a seat-belt sample (a trouserbelt or piece o material o similar length and thickness can be used i a seat-beltsample is not available).

t is recommended that cars are tted with a three-point lap and diagonal belt.•

Te diagonal section should t rom the buckle, up across the centre o the chest•

and over the shoulder on the opposite side.Te lap section should sit across the lap (hip bones).•

For added sa ety, pull upwards on the diagonal strap to minimize all slack,•

particularly in the lap section.Do not allow the lap section to position itsel over the waist. n the event o •

an accident the strength o the hip bones will not be brought into use, and theoccupant could su er internal injuries as their body surges orward, increasing its weight to that o an elephant.

t takes seconds to t a seat-belt. ut it’s seconds that could save your li e.•



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Conclusion

Te orces generated in a km/h accident can increase a vehicle occupant’s body weight to that o an elephant. Tis can be atal or those who choose not to wear aseat-belt. t can also prove atal or those ront seat occupants who have occupantsdirectly behind them that also do not wear a seat-belt.

Tere may be a legal responsibility on occupants to be appropriately restrained, butmore importantly, there is a moral responsibility on all passengers to ensure that theydo not kill their riends and amily because o their actions. Although an occupantmay die as a result o their actions, it is their amily and riends who will be lefsu ering because o their loss.

Read “ / ths o a second” (below). Conclude by stating that “Tere are reasonsnot to wear a seat-belt. Every one is a killer.” Distribute relevant promotional andeducational material rein orcing the objectives o the lesson.

Re erence:

1. Seat belts. exas, United tates, American College o Emergency Physicians (ACEP), (http://www.acep.org/patients.aspx?Link denti er=id&id= & d= &Mo= o&acep itle= eat% elt% Fact% heet, accessed ovember ).

For the next 7/10ths o a second, we are going to takeyou through death in slow motion.

It’s night, you’re tired, and you’re late getting home, soyou’re driving 55 miles per hour on a road not designed

or that speed Your car reaches a curve in the road, butyou make a mistake, too late, the car goes out o controland you hit a solid immovable object, CRASH!!!

1/10th o a second: The ront bumper and chrome rost-ing o the grillwork collapse Slivers o steel puncture thewall to a depth o one and a hal inches

2/10ths o a second: The hood rises,crumples, smashes into the windshieldSpinning rear wheels leave the groundThe enders come into contact with thewall, orcing the rear parts out over the

ront doors Your body continues to

move orward at 55 miles per hour – 20times the normal orce o gravity You nowweigh more than 3000 pounds Your legs,ramrod straight, snap at the knee joints

3/10ths o a second: Your body is now o theseat, torso upright, broken knees pressed against thedashboard The plastic and steel rame o the steeringwheel begins to bend beneath your death grip Your head

is now near the sun visor, your chest above the steeringcolumn

4/10ths o a second: The car’s ront 24 inches havebeen demolished, but the rear end is still travelling

at about 35 miles per hour The hal -ton motor blockcrunches into the re wall

5/10ths o a second: Your ear- rozen hands send thesteering column into an almost vertical position The

orce o gravity impales you on the steering sha t Jaggedsteel punctures your lungs and intercostal arter-

ies Blood spurts into your lungs

6/10ths o a second: Your eet are rippedrom your tightly laced sneakers Thebrake pedal shears o the foorboardsThe chassis bends in the middle Thecar begins its down all, spinning wheels

digging into the ground7/10ths o a second: The entire body o

the car is orced out o shape Hinges tear,doors spring open In one last convulsion, the

seat rams orward, pinning you against the cruelsteel o the steering sha t Blood leaps rom your mouth,shock has rozen your heart YOU ARE DEAD

Total time elapsed: seven tenths o a second!

BOX 1: "7/10ths o a second"

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Partner organizations in the development

o the manual

World Health Organization (WHO)

As the United ations specialized agency or health, the World Health Organizationaims to integrate road sa ety into public health programmes around the world inorder to reduce the unacceptably high levels o road tra c injuries. A public healthapproach is used, combining epidemiology, prevention and advocacy. pecial

emphasis is given to low- and middle-income countries where most road tra ccrashes occur. n recent years WHO has ocused its e orts on the implementation o the recommendations contained in theWorld report on road tra c injury prevention, which it co-produced with the World ank, and in particular on addressing the mainrisk actors or road tra c injuries. Following a United ations General Assemblyresolution on road sa ety, adopted in , WHO acts as a coordinator or roadsa ety initiatives within the United ations system, and to this end has acilitatedthe development o the United ations Road a ety Collaboration – a group o over

international road sa ety organizations, including many United ations agencies.Tis coordinating role was urther endorsed by a ourth United ations General

Assembly resolution, adopted in . Address: World Health Organization, 20 Avenue Appia, CH-1211 Geneva 27,

witzerland

URL: www.who.int/violence_injury_prevention/en/

Contact person: Margie Peden, Coordinator, Unintentional njury Prevention,Department o njuries and Violence Prevention

E-mail: tra [email protected]

World BankTe World ank promotes the improvement o road sa ety outcomes in low- andmiddle-income countries as a global development priority, in accordance with itstransport business strategy “ a e, Clean and A ordable ransport or Development

– ”. t provides nancial and technical support to countries, working through government agencies, nongovernmental organizations and the privatesector to ormulate strategies to improve road sa ety. Te World ank’s mission isto assist countries in accelerating their implementation o the recommendations o the World report on road tra c injury prevention, which it developed jointly withthe World Health Organization in . o achieve this, it emphasizes countrycapacity building and the development o related global and regional partnerships,



Partner organizations

194

with a ocus on the achievement o measurable road sa ety results. n support o thisocus the World ank Global Road a ety Facility has been established to generate

increased unding and technical assistance or global, regional and country activitiesdesigned to accelerate knowledge trans er to low- and middle-income countries andcatalyse increased country investment in road sa ety programmes.

Address: World ank, 1818 H treet, W, Washington DC 20433, United tates

URL: http://www.worldbank.org/grs

Contact person : Anthony liss, Lead Road a ety pecialist, ransport Division,Energy, ransport and Water Department

E-mail: [email protected]

Global Road Sa et Partnership (GRSP)

Te Global Road a ety Partnership is a partnership between business, civil societyand government dedicated to the sustainable reduction o death and injury onthe roads in developing and transition countries. y creating and strengthening links between partners, GR P aims to increase awareness o road sa ety as an issuea ecting all sectors o society. GR P seeks to establish sustainable partnerships andto deliver road sa ety interventions through increased resources, better coordination,management, greater innovation and knowledge sharing, both globally and locally.

GR P is a hosted programme o the nternational Federation o Red Cross and RedCrescent ocieties.

Address: Global Road a ety Partnership, c/o nternational Federation o Red Crossand Red Crescent ocieties, PO ox 372, 17 Chemin des Crêts, CH-1211 Geneva 19,

witzerland

URL: www.grsproadsa ety.org

Contact person: Andrew Pearce, Chie Executive

E-mail: grsp@i rc.org

FIA Foundation or the Automobile and Societ

Te F A Foundation or the Automobile and ociety is a registered UnitedKingdom charity with the objectives o promoting public sa ety and public health,the protection and preservation o human li e, and the conservation, protectionand improvement o the physical and natural environment. ince its establishmentin , the F A Foundation has become a prominent player in promoting roadsa ety around the world. t conducts advocacy to raise awareness about the growing epidemic o road tra c injuries and place road sa ety on the international politicalagenda. t promotes research and the dissemination o results to encourage best




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practice in road sa ety policy, and o ers nancial support to third-party projectsthrough a grants programme.

Address: F A Foundation, 60 ra algar quare, London WC2 5D ,United Kingdom

URL: www. a oundation.org

Contact person: David Ward, Director General

E-mail: mail@ a oundation.org



Glossary of terms

196

Glossary o terms

airbag. a ety device installed in a vehicle that in ates to protect the driver or passengers in case o a collision. Most airbags are tted in the driver and right passenger positions, but some newer cars also contain side airbags.

attachment. Part o the seat-belt assembly including the necessary securing components that enable it to be attached to the seat-belt anchorages.

belt adjusting device. A device enabling the seat-belt to be adjusted according to therequirements o the individual wearer and to the position o the seat. Te adjusting device may be part o the buckle, or a retractor, or any other part o the seat-belt.

booster seat. A seat that boosts a child up, providing a higher sitting height in the vehicle, which allows the adult seat-belt to t properly.

buckle. A quick-release device enabling the wearer to be held by the seat-belt,securing the open end o the seat-belt to the oor mounting by means o a tongue.

Centers or Disease Control and Prevention (CDC). Te CDC includes theational Center or njury Prevention and Control, which has a ocus on preventing

motor vehicle-related injury through research and programmes. t is the principle prevention agency o the United tates Department o Health and Human ervices,

located in Atlanta, Georgia.change in velocity during a collision (∆V). n crash reconstructions, the changein velocity occurring as a result o an impact – usually at the centre o gravity o the vehicle – is widely used as the measure o the severity o a collision. At high speeds,collisions between cars are almost totally inelastic and so there is very little rebound.Tus i a car travelling at km/h strikes a stationary car o the same mass, they willboth undergo a change in velocity o km/h.

child restraint. An in ant seat ( or under year o age) or child sa ety seat ( or– years o age) designed according to the age and weight o the child, o ering

protection in the event o a car crash.

cost. Use o resources that have alternative uses. Costs are generally measured inmonetary terms, but the concept o cost includes any use o resources, not just directout-o -pocket expenses.

cost–bene t analysis. A ormal analysis o costs and bene ts o a programme, in which all relevant impacts are converted to monetary terms ().

diagonal belt. A seat-belt that passes diagonally across the ront o the chest romthe hip to the opposite shoulder.

emergency medical services (EMS).Te services provided by trained personnelusing adequate equipment soon afer an emergency. EM or injuries aim to reduce




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the rates o death rom potentially li e-threatening injuries. Tese services include thecare provided be ore the person reaches the hospital (pre-hospital EM , including care delivered in the eld and transport to a xed site o de nitive care) and themedical care provided in a hospital-based setting.

evaluation. An ongoing process to assess the e ectiveness o a programme inachieving its objectives. Evaluation also aims to identi y problems that may arise with the implementation o a programme, so that concerns are ed back into the planning process and modi cations can be carried out during the implementation.An evaluation is usually designed to try to distinguish the e ects o a programme

rom those o other actors.

FIA Foundation or the Automobile and Society. Established by the Fédérationnternationale de l’Automobile (F A) in as a registered charity in the United

Kingdom, the F A Foundation is a leader in global road sa ety advocacy and a majorsupporter o road sa ety research, working closely with international partners to promote road sa ety and a sustainable approach to mobility.

rst aid. Emergency treatment administered to an injured person at or near theinjury site, prior to receiving pro essional medical care.

ull harness belt.A seat-belt assembly comprising lap, thigh and shoulder straps with a central locking device.

Global Road Sa ety Partnership (GRSP). A global partnership involving business,civil society and governments dedicated to the sustainable improvement o roadsa ety in developing and transition countries.

high-income country. For the purpose o this document the World ankclassi cation has been used to classi y countries, based on gross national income(G ) per capita. A high-income country is one whose G per capita is U $ or more ( ).

high-visibility law en orcement.Patrolling by the police that is easily seen by passing road users, or example random alcohol and sobriety checkpoints.

human capital approach in costing road crashes. Tis approach is based on humancapital theory, which ocuses on the centrality o human beings in the productionand consumption system. Te human capital approach model includes both directand indirect costs to individuals and society as a whole due to road tra c injuries.

uch costs include emergency treatment, initial medical costs, rehabilitation costs,long-term care and treatment, insurance administration expenses, legal costs, workplace costs, lost productivity, property damage, travel delay, psychosocial impactand loss o unctional capacity (3).

integrity o the passenger compartment. Ability o a vehicle’s passenger compart-ment to stay whole and not collapse on impact with another vehicle or object.



Glossary of terms

198

ISOFIX. An international standard attachment that child restraints can beconnected to, with the objective o reducing the likelihood o incorrect tting andmaking restraint removal and tting easy or the vehicle user.

key per ormance indicator (KPI). An indicator against which speci c itemsor services can be compared as a measure o how closely they meet the statedrequirement.

lap and shoulder belt. See three-point lap and diagonal seat-belt .

lap belt. See two-point lap belt .

legislation. Acts or provisions that have the orce o law, i.e. that give the police theright to en orce their provisions and the courts o law the right to impose penalties ().

low-income country. For the purpose o this document the World ankclassi cation has been used to classi y countries, based on gross national income(G ) per capita. A low-income county is one whose G per capita is U $ orless ( ).

middle-income country. For the purpose o this document the World ankclassi cation has been used to classi y countries, based on gross national income(G ) per capita. A middle-income county is one whose G per capita is betweenU $ and U $ ( ).

o set de ormable barrier test. A rontal crash test that aims to reproduce real- world conditions o car-to-car rontal crashes. n this test, the ront o the striking vehicle partially overlaps a de ormable barrier.

Organisation or Economic Co-operation and Development (OECD). TeOECD brings together countries sharing the principles o the market economy, pluralist democracy and respect or human rights.

out-o -position occupant. A vehicle driver or passenger who is out o his or herseating position at the time o the crash – or example, a child lying across therear seat.

passenger airbag. See airbag. passive sa ety device.Any device that automatically provides protection or theoccupant o a vehicle, such as seat-belts, padded dashboard, bumpers, laminated windshield, head restraints, collapsible steering columns and airbags.

pre-hospital care. Te care provided to reduce the e ects o trauma or injurybe ore the injured person reaches a hospital-based setting ( see emergency medicalservices). Tis includes the ormal response provided by trained and equipped personnel, as well as the bystanders’ response provided by lay people.

pretensioner. An additional or integrated device that tightens the seat-belt webbing

in order to reduce the slack o the seat-belt during a crash.




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release mechanism. A red-coloured push button device that, when pressed, releasesthe tongue rom the buckle o the seat-belt.

retractor. Device to accommodate part or all o the strap o a seat-belt.

risk. Te possibility o an unwanted event occurring.

risk actor.A actor that a ects the probability o an unwanted event occurring orin uences the severity o the consequences that arise as a result o the event.

road tra c crash. A collision or incident that may or may not lead to injury,occurring on a public road and involving at least one moving vehicle.

road tra c atality. A death occurring within days o a road tra c crash (3).

road tra c injury. on- atal injury incurred as a result o a road tra c crash.road user. A person using any part o the road system as a non-motorized ormotorized transport user.

sa ety per ormance standard.De nition or speci cation or equipment or vehicle per ormance that provides improved sa ety. uch standards are produced nationally,regionally or internationally by a variety o organizations.

seat-belt. A seat-belt, sometimes called a sa ety belt, is a sa ety harness designed tosecure the occupant o a vehicle against harm ul movement that may result rom acollision or a sudden stop. eat-belts are intended to reduce injuries by stopping the wearer rom hitting hard interior elements o the vehicle or other passengers and by preventing ejection rom the vehicle.

seat-belt anchorage. A point in the vehicle to which a seat-belt is attached.

seat-belt reminder system. ntelligent visual or audible device that detects whetheror not seat-belts are in use in di erent seating positions and gives out increasinglyaggressive warning signals until the seat-belts are used. Te signal may be a buzzer,chime or voice reminder.

submarining. During a collision, sliding o the occupant under the seat-belt into the

oot well compartment as a result o too much slack in a seat-belt assembly.surveillance. ystematic ongoing collection, collation and analysis o data and thetimely dissemination o in ormation to those who need to know so that action can betaken.

three-point lap and diagonal seat-belt . Any seat-belt that is essentially acombination o a lap strap tting over the pelvis and a diagonal strap that ts overthe shoulder. A three-point lap and diagonal seat-belt is much sa er than a lap belt orshoulder belt alone.

tongue. A metal insert connected to the seat-belt and astening into the buckle, only

disconnected by pressing the release mechanism.



Glossary of terms

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ransport Research Laboratory ( RL). An independent, internationallyrecognized centre o excellence in sur ace transport issues.

two-point lap belt. A seat-belt that passes across the ront o the wearer’s pelvic region.

United Nations Economic Commission or Europe (UNECE). Te U ECEstrives to oster sustainable economic growth among its member countries. t provides a orum or communication between tates; brokers international legalinstruments addressing trade, transport and the environment; and supplies statisticsand economic and environmental analysis. t includes the World Forum orHarmonization o Vehicle Regulations (WP ).

United Nations Road Sa ety Collaboration. Established afer the passing o United

ations resolution / , it brings together over organizations to share theirexperiences and expertise on road sa ety.

webbing. Te strap section o the seat-belt system used to counteract the momentumo the vehicle occupant in the rapid deceleration experienced in a crash.

World Bank. A development bank that provides loans, policy advice, technicalassistance and knowledge-sharing services to low- and middle-income countriesto reduce poverty. Te ank’s mission is to ght poverty and improve the living standards o people in the developing world.

World Health Organization (WHO). Te United ations specialized agency or

health, headquartered in Geneva, witzerland.

Re erences

1. Elvik R, Vaa .Te handbook o road sa ety measures. Amsterdam, the etherlands, Elsevier, .2. Country classi cation: classi cation o economies. Washington DC, World ank Group,

(www.worldbank.org/data/countryclass/countryclass.html, accessed ovember ).

3. Economic Commission or Europe ntersecretariat Working Group on ransport tatistics.Glossary o transport statistics, rd ed. RA /WP. / / . ew York, United ationsEconomic and ocial Council, (http://www.unece.org/trans/main/wp /pd docs/glossen . pd , accessed ovember ).

seat belts & child restraints

Documents