Description of the condition
At a time in the world's history when many of the health concerns of the past are showing some indication of improvement, traffic related health concerns are growing. Over 1.2 million people die each year as a result of traffic collisions and hundreds of thousands of others are permanently and seriously injured (WHO 2009). In 2002, road-traffic injuries ranked as the tenth leading cause of death in the world (WHO 2001). In 2004 that ranking rose to seventh, and it is expected that by 2030 road injuries will rank as the fifth leading cause of death (WHO 2009). The developing world bears the brunt of these injuries, over 90% of fatalities occur in low- and middle-income countries, where death rates can be up to twelve or thirteen times higher than in high-income countries (WHO 2009). Apart from the personal losses that these figures represent what is also clear is that these levels of injury represent huge cost burdens to countries with already limited resources (Nordberg 2000; Olukoga 2004; Chandran 2010; Juillard 2010; Mashreky 2010; Bhatti 2011). Work is needed to reduce the number of collisions that occur - through improved functionality of roads, vehicles and drivers themselves. Concurrently, we need to find cost-effective ways of reducing the severity of injuries sustained in the collisions that do occur (WHO 2004).
Description of the intervention
Most injuries sustained by vehicle occupants during a collision are the result of the fact that occupants of vehicles will keep moving even after the vehicle itself has come to a stop (Nordhoff 2005a). Generally in a head-on collision, unless suitably restrained, the occupants will either be ejected through the windscreen or will collide with the dashboard, steering wheel or the seats in front of them, causing serious injury (Nordhoff 2005b). Seat belts are designed to accomplish two key functions - to prevent the occupant from being ejected from the vehicle by the force of impact, and to extend the time that the decelerating force is applied to a person (Prevention Institute 2002). This is important because injury severity is inversely related to the time over which the body is brought to a stop (Nordhoff 2005a; Nordhoff 2005b). Seat belts also spread the area of impact to both a larger and less vulnerable part of the body. Abbas 2011 reported a clearly significant negative correlation between compliance of wearing seat belts and the rate of road traffic deaths (R = - 0.77, F = 65.5, P value < 0.00001); countries with high levels of seat belt usage have experienced marked reductions in traffic deaths. Educational, enforcement based, incentive-based, engineering-based or a combination thereof, are types of interventions to encourage seat belt use (Table 1).
|Including a specific intervention as part of driving lessons and acquiring a license||Random road blocks||Seat belt alarm|
|Advertisement / awareness campaigns|
Traffic fines for not wearing a seat belt
|Unable to start a car without a fastened seat belt, or drive faster than a certain speed without a fastened seat belt|
|Specific extra education for previous offenders||Suspension/banning of previous offenders|
Offering education class as an alternative to prosecution for seat belt offences
|Putting the responsibility on the passenger|
|Point systems (increasing points for repeating offenders)|
How the intervention might work
Since the 1950s seat belts have been factory-fitted to most vehicles and today around 90% of the industrialised countries have adopted seat belt legislation making it mandatory for selected, if not all, vehicle occupants to wear seat belts. However, the simple passing of laws has not in itself been found to be sufficient to change seat belt use; since the 1970s various seat belt interventions have been rolled out across many developed countries (Prevention Institute 2002). These typically have included persuasive and coercive components: encouraging voluntary use of seat belts by educating the public about their benefits, and enforcing the use of seat belt wearing though primary or secondary enforcement (Dinh-Zarr 2001). Primary enforcement safety belt laws allow police to stop and ticket motorists solely for being unbelted (Dinh-Zarr 2001). Secondary laws only allow police to issue a safety belt citation if the vehicle has been stopped for another reason (e.g. speeding) (Dinh-Zarr 2001) (Table 1). Education and enforcement interventions have also been supported by technological (engineering) solutions, such as the use of seat belt reminder alarms in vehicles which have become common features of vehicle design. As a consequence of these three factors - education, enforcement and engineering - most countries of Europe now exhibit very high seat belt wearing rates, with variable levels being reported in the United States, reflecting mixed policies at the state level and the application of inconsistent campaigns across the country and poor levels of seat belt use in most developing countries (Prevention Institute 2002).
While it is accepted that seat belt wearing rates have been positively influenced by the type and extent of interventions used to encourage compliance, little research has been carried out to determine the factors which influence the effectiveness of individual interventions or to assess the impact of multiple intervention initiatives. There is little understanding of whether coercion or encouragement is more effective, and little appreciation of whether these are context specific. The research into the effects of specific interventions, while generally positive, suggests that increasing seat belt usage is not always a simple task, and that there may be other factors at play such as risk compensation that undermine the effectiveness of seat belts by increasing exposure to risk (Streff 1989).
Why it is important to do this review
The aim of this systematic review is to assess the effects of interventions, either educational, enforcement based, incentive-based, engineering-based or a combination thereof, to encourage seat belt use (Table 1). This will contribute by informing future research, guide policy and practice, and facilitate the design of community-based prevention programs that are effective.