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6 approach involving that specific countermeasure may work, Most of the countermeasures in the Voluntary Action and another may not. This can happen in all four of the Group involve communications. Historically, many of countermeasure groupings. For example, in the laws area, it these efforts have been of poor quality, consisting of passive is possible that a law that works in one state will not work in messaging, sloganeering, exhorting people to do--or not another, since laws (e.g., seat belt laws, administrative license do--some behavior, and delivered to an undifferentiated revocation [ALR] laws) vary in terms of coverage and penal- audience over the short term. The simplistic assumption is ties. In the laws/enhancements area, enforcement programs that if individuals are made aware of behaviors that will can vary in intensity and duration, and may be differentially enhance their personal health or safety and urged to adopt effective. In the treatment/sanctions area, alcohol treatment these behaviors, they will do so. Seemingly logical, this programs can differ markedly. However, this is most likely to sequence of events is unlikely to happen. It is well established be an issue in the grouping for voluntary actions only where that information-only programs are unlikely to work, espe- programs promoting a specific action can vary widely, rang- cially when most of the audience already knows what to do. ing from a passive public information campaign based on Therefore, highway safety messages conveyed in signs, pam- materials sent through the mail to multiple face-to-face in- phlets, brochures, on buttons, etc. may increase awareness of teractions involving sophisticated behavior change models, the health issue being addressed and reinforce social values, and possibly involving other inputs. The latter may work; the but are unlikely to have any effect on behavior. Behaviors that former may not. are particularly difficult to change, such as getting a motor- Another warning concerning effectiveness ratings was cyclist to buy and use a helmet, are least likely to be affected raised in Countermeasures That Work (NHTSA, 2007b), by advice or urgings to do so. namely that evaluation studies generally examine and report Lecture-oriented education programs that are information- on high-quality implementations of countermeasures, so that only in nature also are likely to be ineffective, as are short- the effectiveness data are likely to show the maximum effect term programs and messages delivered only once or twice. that can be realized. That is, the countermeasure in question Extreme fear or scare techniques also are likely to have no may not work, or work as well, with lesser efforts. Also, it more than a short-term emotional effect, especially when should be noted that while a particular approach may not directed at adolescents. work by itself, it may facilitate acceptance of an approach that Programs recommending driver behavior that are more will reduce injury (e.g., public information and education likely to be effective include public information programs [PI&E] may affect public acceptance making passage of a law that involve careful pre-testing of messages to make sure the more likely). message is relevant to the group being addressed and care- The remainder of this chapter will discuss each counter- ful delineation of the target group to make sure the messages measure category in turn, along with the criteria derived that reach the target group in sufficient intensity over time. distinguish effective and ineffective countermeasures within These are the aspects involved in successful social market- that category. Then, each countermeasure within that group ing programs. In the education arena, some success (mostly will be rated as follows: in other health areas) has been achieved through programs using theory-based behavior change models, and interactive Proven effective; methods to teach skills to resist social influence through role Likely to be effective; playing, behavior rehearsal, group discussion, and other Effectiveness is Unknown/Uncertain/Unlikely; or means. In a few cases, Proven Not to Work. However, even high-quality public information and education programs rarely work by themselves to change in- dividual behavior, although their contribution can be criti- Countermeasure Categories cally important when combined with other prevention efforts (e.g., in support of law enforcement or as part of broader Class 1: Voluntary Action community programs). According to the research literature A popular approach in the behavioral field has been to urge (Williams, 2007a), programs involving voluntary actions people to take appropriate actions through public informa- that work on their own include those targeting children, tion, educational programs, mass media, and training used whereas programs targeting teenagers or adults are not likely alone. Given the barriers to change discussed earlier, it is not to work. Unlike adults, children do not have well-developed easy to change driver behavior in this manner. This subject is safety behavior patterns and so are more amenable to treated extensively in Public Information and Education in the change. Programs also work that communicate health Promotion of Highway Safety (Williams, 2007a), which forms knowledge not previously known. One example of this is the the basis for the following discussion. shift of children from front to rear seats to avoid air bag

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7 inflation dangers, a "new" knowledge that was largely driven Education to encourage pedestrians to increase their con- by public education programs. Programs where the com- spicuity (-); municator has some control over resources or over the Driver education in regard to pedestrians (-); audience also are more likely to be successful. These would Programs to teach driver awareness about motorcyclists (-); include employer programs, parents influencing their chil- PI&E about driver fatigue (-); dren, and alcohol servers influencing patrons. Finally, high- PI&E about distracted driving (-); quality public information and education programs that PI&E on sleep disorders for general population and phy- are part of broad-based community programs have also sicians (-); been successful. Employer programs for shift workers, medical interns (+); The 38 voluntary action countermeasures (the largest group Alternative transportation for alcohol-impaired drivers (+); of any of the four categories) are listed below, sorted according Designated driver programs (0); to their effectiveness rating. Note that this group also includes Motorcycle helmet use promotion programs (-); three items that research has clearly shown do not work to PI&E on drinking and motorcycling (-); reduce crashes and, in fact, can increase them: novice driver Education to encourage motorcyclists to increase their education (when that education leads to licensure at an age conspicuity (-); which is younger than would otherwise be the case without Programs to help police detect impaired motorcyclists (0); the education), skid training for novices, and traffic viola- Communications and outreach regarding impaired pe- tor school in lieu of penalties. Regarding the category of destrians (-); Unknown/Uncertain/Unlikely, see Appendix A for the ration- Extreme fear and scare tactics in youth programs, e.g., fake ale and references to further separate this group into: (+) some deaths, mock funerals (-); basis for thinking that it might work; (0) unknown or no High school driver education (not leading to early learning/ opinion; and (-) some basis for thinking that the counter- licensing) (0); and measure will not work. School bus training for children (+). Proven Proven Not to Work School pedestrian training for children; High school driver education (leading to early learning/ Programs to get parents to put children in rear seats; licensing); Booster seat promotions; and Advanced driver education, skid training; and Child bicycle helmet promotions. Traffic violator school in lieu of penalties. Likely Class 2: Laws, Regulations, Policies Responsible beverage service and Many of the demonstrable gains in changing behavior in Parent guiding teen licensing. ways that reduce motor vehicle injuries have come through laws and regulations. The power of laws is illustrated by the abrupt changes in behavior that occur coincident with their Unknown/Uncertain/Unlikely introduction. For example, on the day British Columbia's Child pedestrian supervision training for caregivers (+); seat belt use law went into effect, belt use was 30 percentage Child safety clubs (+); points higher than it had been 24 hrs earlier (Williams and Bicycle education for children (+); Robertson, 1979). School-based alcohol education programs to reduce drink- Not all laws work, however. Laws that work best incorpo- ing and driving (0); rate elements associated with high deterrent capabilities. PI&E for elderly drivers (-); That is, they are well known to the public, and they are PI&E for low belt users (+); enforceable laws, based on easily observable behavior and Motorcycle education and training courses (-); objective criteria (e.g., motorcycle helmet use laws). This Formal driver education courses for elderly drivers (-); leads to the expectation that not complying with the law will Bike fairs, rodeos (+); result in apprehension and sanctioning. Also advantageous Driver training about sharing the road with bicycles (-); are laws where enforcement is done not only by the police, Teaching bike rules/safety in driver education (-); but by parents (e.g., bicycle helmet laws for children, or grad- Education encouraging bicyclists to increase their con- uated licensing laws for adolescents). Department of Motor spicuity (-); Vehicles (DMV) rules that have to be followed, and ordinances

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8 and other across-the-board policies also are more likely to Referral of elderly drivers to licensing agencies (+); work. Policies work that force changes that result in positive Licensing screening and testing for elderly drivers (+); and outcomes. For example, motorcycle helmet laws force riders Licensing restrictions for elderly drivers (+). to wear a helmet. Laws less likely to work on their own are those that are not well known, or for which the behavior is not easily observ- Class 3: Laws Plus Enhancements able by police and therefore not easily enforced (e.g., open If the public to whom the law applies is not aware of the container laws). Laws that apply only to a portion of the pop- law, or there is little enforcement, or little perceived enforce- ulation performing the behavior (e.g., motorcycle helmet ment, positive effects of laws can be diminished or eliminated. laws that apply only to young motorcyclists) are difficult to Thus, the effects of laws can be enhanced by special enforce- make effective, especially when the penalties are weak. Laws ment programs, publicity about the law and its enforcement, where the criteria are not explicit also are less likely to be and--in some cases--by special equipment such as passive successful (e.g., aggressive driving, fatigue, and distracted alcohol sensors to enhance enforcement. When one or more driving laws). of these elements is combined with laws that are easily enforce- able, success is likely. Success is less likely when laws are not Proven easily enforceable because the criteria for enforcement are vague or the behavior is difficult to observe. Bike helmet laws for children; Graduated driver licensing (GDL); Extended learner permit; Proven Night restrictions (for young drivers); Sobriety checkpoints; Passenger restrictions (for young drivers); Saturation patrols for alcohol-impaired driving; Administrative license revocation laws; Preliminary breath test devices; BAC test refusal penalties; Passive alcohol sensors; Primary seat belt law; Short, high-visibility belt law enforcement; Speed limits; Automated enforcement for speed, red light running; Motorcycle helmet laws; and Mass media support of alcohol enforcement or other Reduced speed limit regarding pedestrians (proven in programs; Europe). PI&E supporting enforcement of seat belt laws; and Community programs, including age 21 enforcement. Likely Ice cream vendor ordinance; Likely Local primary seat belt laws; Integrated enforcement (alcohol, seat belts, speeding); Adult bike helmet laws; Zero-tolerance enforcement; License renewal policies for elderly drivers; and Vendor compliance checks for age 21 enforcement; and License actions for underage alcohol violations. Sustained seat belt enforcement. Unknown/Uncertain/Unlikely Unknown/Uncertain/Unlikely General cell phone laws (+); Aggressive driving enforcement (+); Open container laws (0); GDL enforcement (+); Lower BAC limit for repeaters (+); Enforcement of pedestrian rules targeted to drivers and Cell phone laws as part of graduated licensing (+); Belt use as part of graduated licensing (+); pedestrians (-); Enforcement of bike rules (-); and Motorcycle licensing laws, especially in regard to having a Enforcement against unapproved motorcycle helmets (+). valid license (0); Belt laws with significant exclusions (0); Keg registration laws (0); Class 4: Sanctions and Treatments Medical advisory boards for elderly drivers (0); Aggressive driving laws (-); Special penalties and treatments also can supplement Driver fatigue and distracted driving laws (-); laws. Sanctions that are well known to violators, have a high