Safety belt promotion: Theory and practice

Acud Aml & Prev Vol Prmted m Great Bntam

20. No

1. P&I 27-38,

oml-4575188 B 1988 Pergamon

1988

$3 Ml+ 00 Journals Ltd

SAFETY BELT PROMOTION: THEORY AND PRACTICE GARY D. NELSGN School of Health, University of Nebraska-LincoIn, Lincoln, NE 68533, USA and PATRICK B. MOFFIT University of Northern Iowa, Cedar Falls, IA, U.S.A. (Received 11 April 1986; in revised

form20 January 1987)

Abstract-The purpose of this paper is to provide practitioners a rationale and description of selected theoretically based approaches to safety belt promotion. Theory failure is a threat to the integrity and effectiveness of safety belt promotion. The absenceof theory driven programs designed to promote safety belt use is a concern of this paper. Six theoretical models from the social and behavioral sciences are reviewed with suggestions for application to promoting safety belt use and include Theory of Reasoned Action, the Health Belief Model, Fear Arousal, Operant Learning, Social Learning Theory, and Diffusion of Innovations. Guidelines for the selection and utilization of theory are discussed.

Motor vehicle accidents represent one of the leading causes of death in the United States today. An examination of motor vehicle mortality and disability reveals a devastating scenario in terms of medical, psychological, social, and economic costs [Centers for Disease Control, 1984; National Highway Traffic Safety Administration [NHTSA], 1983; Healthy People, 19795. It is not surprising that motor vehicle safety, including safety belt use, is a priority national health promotion objective [Promoting Health/Preventing Disease: Objectives for the Nation, 19801. Public health strategies which reduce the risk of injury and death among motorvehicle occupants are needed. In response, efforts promoting active and passive approaches to occupant protection have been initiated at the federal and state levels. Among these approaches, safety belt use is regarded as a viable method of injury control with the potential to reduce motor vehicle related mortality and disability [Goldbaum, et al., 1986; Insurance Institute for Highway Safety, 1985a; Caldwell, 1985; Campbell, et al., 1984; Sleet, 1984; Lawson, et al., 1984; Nichols, 1982; Reichelderfer, 19761. However, programs promoting voluntary restraint use have met with variable and, too often, only modest success. In response to the inadequacies of voluntary safety belt programs and recent federal initiatives, states have relied on mandatory use legislation [Caldwell, 1985; Fourteen States Mandate Seat Belts, 1985; Insurance Institute for Highway Safety, 1985b] and traffic enforcement [Jonah and Grant, 1984; Jonah, 19821 to induce people to buckle up. Despite increased safety beit use following legislation and traffic enforcement, there is evidence that such activities are not a panacea for sustaining high rates of use [O’Neil, 3986; Jonah and Lawson, 1984; Jonah, Dawson, and Smith, 19801. Achieving and maintaining high rates of safety belt use may require mandatory use legislation and theoretically sound educational programs [Moffit, 19851. Promoting voluntary use of safety belts and child restraints remains a critical health issue since state legislation mandating safety belt use has been questioned and even repealed. Similar action was taken by 27 states which repealed the use of motorcycle helmets [Baker and Dietz, 19791. According to Sleet [1984]: “In the final analysis, however, the full potential for health promotion strategies to increase safety belt and child restraint use will rely on active and voluntary participation by individuals who value their own health.” (p. 124)

21

18

G. D. NELSON and P. B MOFFIT

Efforts to promote injury control by increasing positive health behaviors and decreasing negative health behaviors typically emphasize voluntary changes in knowledge, attitudes, beliefs, values, and skills. Understanding the behavioral causes of motor vehicle injuries including nonuse of safety belts is a prerequisite to theoretically sound safety belt promotion programs. Although there are numerous descriptions of safety belt promotion strategies and program evaluations in the research literature, the theoretical framework of many safety belt programs has not been adequately articulated. Social and behavioral science theory offers practitioners useful models for planning, implementing, and evaluating safety belt programs promoting voluntary use. The purpose of this paper is to provide practitioners an understanding of and rationale for the use of theory in safety belt promotion programs. THEORY

BUILDING

Theory building is a primary function of science. According to Kerlinger [ 19731. “A theory is a set of interrelated constructs (concepts), definitions, and propositions that present a systematic view of phenomena by specifying relations among variables with the purpose of explaining and predicting the phenomena.” A theory organizes information about health behavior into a broader conceptual framework for greater application. A theory allows for a meaningful interpretation of the factors which influence health behavior and how behavior can be changed. Theoretical constructs serve as guides for discovering explanations for behavior and formulating approaches to behavior change or maintenance. With the emergence of health promotion and education programs has come an enthusiastic spirit of “get the show on the road.” For reasons of program visibility, accountability, and competition for limited resources, many practitioners have opened the show without proper scripting [Davis and Moffit, 19821. Effective health promotion programming requires that practitioners understand the epidemiology of motor vehicle injuries including factors which predispose, enable, and reinforce safety belt behavior. Green, et al., [1980] define these behavioral antecedents as follows: predisposingfactors which provide a motivation for behavior (knowledge, attitudes, beliefs, values); enabling-factors that allow a motivation to be realized (skills); and reinforcing-factors that provide a continuing reward for a behavior (incentives). Ericksen and Gielen (19831 have applied these concepts in the design of a safety belt program. The absence of social and behavioral science theory and research is a frequent criticism of interventions directed at health behavior change [Parcel, 19831. Suchman [1969] suggested that one reason for program failure is the lack of a theoretical foundation which adequately addresses the factors which predispose, enable, and reinforce health behaviors (Fig. 1). The absence of theory represents a possible explanation for the modest results observed in safety belt promotion programs. For example, a safety belt program and evaluation without addressing may reflect exemplary planning, implementation, factors affecting the individual’s initiation and/or maintenance of safety belt use. Further, as a result of theory failure, the determinants of seatbelt use may not be identified and modified. Practitioners will find it difficult to replicate the results of a successful program if its theoretical framework remains undefined. Without a theoretical framework, practitioners may have difficulty labeling the successful and unsuccessful elements of an educational/enforcement program. The neglect of theory also presents a critical ethical dilemma. Few health professionals would consider it ethical to employ a theoretically unsound therapeutic approach in the treatment of illness. The use of ineffective or unproven strategies in safety belt programs should be viewed with the same seriousness. The absence or misuse of theory when applied to safety belt programs may result in undesirable outcomes including but not limited to health consequences, reduced self-efficacy, resistance to educational programs, wasted public concern, and diminished professional credibility. Practitioners should consider the impact of their efforts and carefully attend to theoretically based programming. The design and implementation of safety belt promotion programs should be theory

Safety

29

belt promotion

SUCCESSFUL SAFETY BELT PROGRAM

set in PROGRAM -CAUSAL motion

IMPLEMENTION FAILURE

which would not set PROCESS-hove led*SAFETY BELT PROGRAM -in-CAUSAL USE motion not addressed to

THEORY FAILURE

set in

BELT USE

did CAUSAL PROCESS-nol leod4AFETY BELT USE not addressed to

PROGRAMmotion

MEASUREMENT FAILURE

leading PROCESS -SAFETY addressed t0

set in PROGRAM -CAUSAL motion

leoding PROCESSaddressed

Fig. 1. Types of program

to

SAFETY BELT USE (not detected)

failure.

driven. The selection of a theoretical model or combination of models should be based on empirical evidence of effectiveness, appropriateness, and compatability with factors which predispose, enable, and reinforce safety belt use. Six theories which have operationally defined constructs are presented and include Theory of Reasoned Action. Health Belief Model, Fear Arousal, Operant Learning, Social Learning Theory, and Diffusion of Innovations. These theories have been successfully used in health education programs promoting voluntary behavior change. A variety of factors which influence the direction and motivation of voluntary behavior are identified by these theories. General directions for the application of these theoretical models to safety belt programs are provided. THEORY

OF

REASONED

ACTION

Fishbein’s Theory of Reasoned Action (Behavioral Intentions Model) provides a framework for understanding the relationship between attitudes, beliefs, intentions, and behavior [Ajzen and Fishbein, 1980; Fishbein and Ajzen, 1975; Fishbein, 19671. An individual’s behavioral intention determines the probability of performing a specific behavior. The immediate determinant of action is the person’s intention to perform the behavior. According to this model, there is a strong relationship between intentions to use safety belts and actual safety belt use. There are two determinants of behavior intentions: (1) a personal or attitudinal factor which includes the individual’s attitudes toward safety belt use and attitudes about the results of safety belt use, and (2) a social or normative factor which includes normative beliefs-the individual’s perception of what significant others believe and do with respect to safety belt use (subjective norm). The determinants of behavioral intentions are identified in Fig. 2. The Behavioral Intentions Model can be useful in the development of a safety belt promotion program. Following an assessment of an individual’s attitudes and normative beliefs, appropriately focused educational programs can be developed. For example. the safety belt behavior of some individuals may be determined more by attitudes (“I like wearing my seatbelt because it makes me feel more secure.“) than normative beliefs (“My children think I should wear a seatbelt.“). The application of this theory in an educational program should include efforts to influence the individual’s intentions to use safety belts by (1) determining an individual’s most important attitudes about safety belt use and the obtained results, and (2) identifying and utilizing significant others including family, peers, or co-workers whose attitudes, behaviors, and expectations reinforce safety belt use and, as a significant other, motivates the individual to comply. Fhaner and Hane [ 19741 have provided practitioners an example of a safety belt program which incorporates the behavioral intentions model. Other investigators have identified salient attitudes associated with safety belt use which may have important implications for program

30

G. D. NELSON and P. B. MOFFIT

Behavioral beliefs

Beliefs: s-)

about

81 evaluation

outcome of

Att itudes the

behavior

outcome 1 Behavioral Intentions

Normative beliefs

beliefs:-----_)

a----jSafety Belt

Use

Subjective Norm

of others

81 motivation

about

to

comply Fig. 2. Theory of reasoned action.

planning [Gielen, et al., 1984; Hoadley, Struckman-Johnson, and Osgood, 1984; Page, 1984; Jonah and Dawson, 1982; [Knapper, Cropley, and Moore, 1976; Neumann, et al., 1974; Sweetser, 19671.

HEALTH

BELIEF

MODEL

Based on value expectancy theory, the Health Belief Model identifies factors influencing preventive health practices [Becker and Rosenstock, 1978; Becker, 1974; Rosenstock, 19741. The likelihood of adopting a preventive health action such as safety belt use is determined by the individual’s beliefs among four dimensions: (1) perceived level of susceptibility to a particular health threat; (2) perceived degree of severity of the consequences which result if a health threat occurred; (3) perceptions of the potential benefits or effectiveness of a recommended preventive action in reducing susceptibility and/or severity; and (4) perceptions of consequences and other barriers that deter the individual from taking action. The model indicates that a cue to action which increases individual awareness of the threat may trigger action. The health belief model has since been reorganized to include a general health motivation dimension-the perceived value of health [Becker, et al., 19771. The major components of the model are illustrated in Fig. 3. The Health Belief Model can guide the practitioner in diagnosing and targeting beliefs which influence safety belt behavior. According to the model, drivers/passengers must feel threatened in order for safety belt use to occur. Perceptions of threat are influenced by two beliefs: (1) the individual must feel susceptible/vulnerable to any number of undesirable outcomes if not wearing a safety belt, such as injury, traffic citations or peer pressure, and (2) the consequences of nonuse must be recognized as sufficiently severe for the individual (“A motor vehicle-related injury affecting me or my family would have a major impact on my physical health, emotional health, social functioning, and financial well-being.“). In addition to modifying or clarifying perceptions of threat, a safety belt promotion program based on the health belief model should facilitate awareness of the benefits and barriers to action and provide appropriately designed cues to action. Research by Robertson, O’Neill, and Wixon [1972] suggested that messages regarding benefits of seat belt use emphasize comfort and convenience. Finally, this model can be used to teach individuals to recognize and take action on environmental cues or events associated with safety belt use such as observing children unrestrained in a passing car, approaching a police car, traffic accident, or hazardous road conditions. Beliefs regarding perceived susceptibility, severity, and benefits/barriers

31

Safety belt promotion

Modifying Factors Perceptions Severity and

to Action

of -

i Perception of Threat -+

J Liklihood of Wearing Safety Belts

Perceptions of Susceptibility

Benefits-Barriers

t Cues to Action Fig. 3. Health belief model.

to action have been assessed and/or modified in a number of research studies [Schawlm and Slavic, 1982; Tarrance and Associates, 1982; Moffit, 1981; Helsing and Comstock, 1977; 1975; Neumann et al., 1974; Fhaner and Hane, 1973; and Robertson, 19721. FEAR

AROUSAL

More than 15 years have passed since Higbee 119691,McGuire 119691, and Leventhal on the acceptance of health recommendations. The findings, sometimes contradictory and often confusing, explained responses to fear arousing messages, the most effective level of fear, the recipient and situational variables which affect the persuasiveness of the fear communication. Later research described motivational constructs of fear [Beck and Frankel, 1981; Leventhal, 19711, personahty characteristics [Loo, 1984; Russell, Bulloci, and Corenblum, 19771, and cognitive variables [Sutton, 1984; Sutton, 19791 assumed to effect an individuals response to health messages. Individual differences in response to various types of threats and protective recommendations add further complexity to an understanding of the effects of fear messages. Various models have been offered to explain the operation of fear in eliciting protective actions. A common assumption is that fear messages will cause anxiety and a desire to control the danger. The fear messages may emphasize physical, emotional, or other risks. The recommended behavior will be adopted if it is perceived as leading to a reduction of the threat. The most effective use of fear includes a threatening message followed by appropriate and effective recommendations. Yet, misinformation may evoke a level of fear which lessens the effectiveness of a recommendation to use safety belts (“I’m afraid of using my safety belt because I might be trapped if an accident occurred.“). The use of moderate- to high-threat appeals in safety belt promotion efforts appears to yield favorable results. Berkowitz and Cottingham [1960] found strong fear to be more effective in safe-driving practices. Loo [1984] reported more frequent safety belt use was associated with higher fear of death and dying of both oneself and others. Research by Moffit and Nelson 119863 determined that high fear appeals were superior to low levels of fear in evoking acceptance of mandatory safety belt laws. Further, this research suggested that a moderate level of fear arousal has a notable impact on the acceptance of such preventive recommendations. Educational programs may draw from various approaches for eliciting emotional arousal to convince people of the threat posed by nonuse of restraints. For example, a mechanical device called the ‘Lconvincer” allows the individual to feel the impact of a crash while positioned in a simulated automobile seat [M&night and McPherson, 19823. The use of educational methods which personalize the consequences of not using restraints or noncompliance with the law are valuable. Vivid descriptions of the consequences of driving unrestrained may provide sufficient levels of fear arousal to facilitate safety belt use [see National Highway Traffic Safety, 1984, for case examples]. Ultimately, the effectiveness of fear arousal will depend on drivers and passengers being convinced safety belts reduce perceived threats and the person is capable of consistent usage. [ 19701 reviewed the effects of fearful threat communications

G. D. NELSON and P. B. MOFFIT

32

)c

ResDonse

Types

of

Contingencies

( Reinforcing)

Exomples

Reward Conditioning Escape Conditioning Avoidance Conditioning Punishment Conditioning Operant Extinction Reinforcement

Stimulus

Social 8 Monetary Reinforcement Peer Pressure Traf fit Violation Job Reprimand No reinforcing stimulus

Schedules

Examples

Fixed Ratio Fixed Interval Variable Ratio Variable Interval

I reinforcement/25 I reinforcement I reinforcement/ I reinforcement/ Fig. 4. Operant

OPERANT

learning

uses per week IO, 25,5 uses week, day,

theory

LEARNING

The process of modifying behavior by environmental manipulations is referred to as Operant Learning [Skinner, 19383. Behaviors that have favorable consequences are more likely to be repeated and at higher rates than behaviors not having favorable effects. Using the operant learning model, favorable consequences of a behavior serve as positively reinforcing stimuli. How the reinforcement is scheduled has implications for behavior change. For example, desired behaviors can be initially shaped on a continuous or fixed ratio schedule while maintenance of behavior may be better achieved by intermittent reinforcement. Undesirable behaviors can be eliminated through escape and avoidance conditioning or extinction. Five contingencies in operant conditioning which influence the operant response are described in Fig. 4. The application of operant learning principles does not always occur in educational settings. For example, the enforcement of mandatory safety belt use laws may be interpreted as one method of operant conditioning. Educational interventions promoting safety belt use have successfully used a variety of incentives and reinforcement schedules [Nelson and Bruess, 1986; Campbell, Hunter, and Stutts, 1984; NHTSA, 1984; Sleet, 1984; Sheard, Kane, and Dane, 1984; Geller and Bigelow, 1983; Geller. Davis, and Spicer, 1983; Geller and Hahn, 1983; Geller, 1982; Geller, Patterson, and Talbott, 1982; Geller, Johnson, and Pelton, 1982; Christophersen & Gyulay, 19811. The National Highway Traffic Safety Administration [NHTSA, 19841 publication entitled: Profif in Safety Belts identified six types of worksite incentives to increase safety belt use which included work-related privileges, immediate valuables, promotional items, exchangeable tokens, chance to win contests, and social attention (Fig. 5). Sleet and Geller [1986] provided recommendations regarding the use of incentives in safety belt promotion programs. These include: rewards are more effective than punishments; low cost incentives result in cost-effective increases in safety belt use; intermittent rewards have longer-lasting effects; incentives are more effective in combination with education; delayed rewards can be as effective as immediate rewards, family involvement leads to higher safety belt use; and a combination of individual and group rewards yields the best results. SOCIAL

LEARNING

THEORY

Based on Social Learning Theory, Baranowski’s [1979] process of health behavior change appears to be a useful model for designing safety belt promotion programs. According to this model, behavior change includes the following sequence of steps: pretraining, training, initial testing, and continued performance. Critical factors in the behavior change process must be addressed in each stage [Parcel and Baranowski,l981].

33

Safety belt promotion time

off

extra

break

Exchangeable Token

cash t-

food ticket

refreshments

rebate

parking

coupon

gift

special

certificate

assignment

lottery

candy

ticket

trinket flower

bingo

number

pen

poker

cord

coffee

game

mug

litter

I

to

event

preferred

Pfomotionol Item ~~~

coupon

symbol

bog

car

wox

tire

gouge

roff le coupon

name

safety

newspaper

buttom bumper

I

posted picture

sticker key

chain

letter

t-shirt

of

commendot

safety poster

in

TV

ion

interview

I hondshake

Ftg. 5. Types of safety belt incentives. In the pretraining stage, the individual’s expectations (what will happen) and expectancies (the value of what happens) must be considered. Unrealistic expectations regarding safety belt use require modification. Behavioral capability, the ability to correctly perform a behavior, is a prerequisite to behavior and the focus of the training stage. Behavioral capability, is achieved through knowledge and skill proficiency. Specifically, the individual must be knowledgeable of the behavior to be performed, and how it is to be performed. Skill development is the other critical aspect of behavioral capability and is enhanced through instruction and practice. As an example, proper use of child restraints requires both knowledge and skill. Stage three, the initial testing phase, focuses on efforts to enhance self-efficacy-the confidence an individual has in his/her ability to perform the behavior [Bandura, 1986; 1977a; 1977b]. This confidence is a result of previous successful performance, vicarious experiences, verbal encouragement, and emotional arousal. The fourth and final stage is continued performance of a behavior. Self-control and the ability to initiate and maintain a behavior over an extended AAP

20:1-c

G. D. NELSONand P. B. MOFFIT

34

period of time is the desired outcome. The use of monitoring systems, diaries, and behavior change contracts offer a means by which continued performance may be sustained [King, 19821. Components of the Baranowski model are identified in Fig. 6. The individual’s awareness and anticipation of the consequences of restrained and unrestrained motor vehicle travel may be used to affect safety belt use. The perceived consequences serve informational, motivational, and reinforcing functions for the individual [Bandura, 19861. The informational function occurs when an individual understands the effects of using safety belts. By observing these effects, the individual is able to learn what behaviors are appropriate for certain settings. Knowledge of behavioral consequences also serves a motivational function. Based on past experiences, an individual forms outcome expectations and learns to anticipate future effects of one’s actions. The reinforcing dimension of behavioral consequences provides effective regulation of behaviors. That is, the strength of future behaviors such as safety belt use are influenced by the anticipated consequences. The application of Social Learning Theory in promoting safety belt use requires an assessment of the target population’s outcome expectations regarding such use. Individual expectations of the risks of accidents, injury, and the probability of arrest and prosecution under mandatory use laws should be considered. Informational programs, skill training, and modeling can be utilized to promote the behavioral capability of the individual. Structuring successful attempts to wear safety belts may enhance self-efficacy. Finally, self-monitoring and behavioral contracting may be used to help the individual achieve the self-control necessary for maintenance of safety belt use. A social learning approach to safety belt promotion has been described by Allen and Bergman [1976]. Derived from Rotter’s Social Learning Theory [1954], Locus of Control is a type of belief which relates to the individual’s perceived connection between his/her behavior and its consequences. Wallston [1982] has defined health locus of control as the belief about “who or what is the agent that determines the state of their health” (p. 56). Individuals who value their health and believe that their behavior influences their health are most likely to behave in a health-enhancing fashion. Individuals who hold an internal locus of control orientation believe that what happens to them in terms of health, illness, or recovery is due to his/her own behavior. Externally oriented individuals believe that health, illness, and recovery are due to fate, luck, chance, or outside agents such as other people. Internal-external locus of control is not a true dichotomy of beliefs. but is continuous across a variety of experiences. The health locus of control construct and measurement scales have been described in Health Education Monographs [Spring, 19781.

Method

Task I.

Pretraining

Expectation

8

Educational

Diagnosis

Expectancy II.

Training

III. Initial IX

Testing

Continued Performance

Behaviora I Capability

Ski1 I Training

Self - Efficacy

Modeling

Self -Control

Monitoring Stimulus Contracting

Fig 6. Social learning theory

Control

35

Safety belt promotion

Health Locus of Control has important implications for safety belt promotion programs. First, attributing outcomes to one’s behavior is a necessary step in getting the individual to accept more responsibility for safety belt use. Assuming personal responsibility for health behavior, including safety belt use, reflects an internal health locus of control orientation. An individual who maintains an external locus of control orientation to safety belt use relies on outside agents to influence behavior. This individual is less likely to adopt the health promoting behavior. Safety belt promotion programs may be more effective if strategies are included to help the individual recognize the relationship between behavior and its outcomes and accept greater responsibility for initiating and maintaining health behavior. Included among the strategies promoting an internal locus of control orientation may be rewards for self-initiated behavior, self-concept enhancement, and the elimination of reasons for refusing to wear safety belts [Aronson, 19801. DIFFUSION OF INNOVATIONS Diffusion theory refers to the rate and process by which innovations or new ideas spread through a population [Rogers and Shoemaker, 19711. Innovations refer to new ideas, behaviors, products, or services. Adoption defines the process in which innovations are considered by the individual. There are four steps in the innovation-decision process. These include: knowledge, persuasion, decision, and confirmation. According to Rogers and Shoemaker, the knowledge stage involves the individual’s understanding of the innovation. The persuasion stage includes the development of an attitude toward the innovation. The decision stage refers to the individual’s choice to adopt or reject the innovation. Finally, the confirmation stage includes efforts by the individual to seek reinforcement for the decision. Characteristics of an innovation which enhance adoption include the individual’s perception of the relative advantage, compatibility, simplicity, trialability, and observability of the innovation. Although the theory has not been applied to safety belt use, the underlying concepts appear appropriate for voluntary and compulsory efforts promoting health behavior. The innovation decision process which precedes adoption is illustrated in Fig. 7. A major task of safety belt promotion programs would be to provide opportunities to participate in the innovation decision process. This includes activities designed to help the individual learn prerequisite information and skills for decision making. Figure 7 identifies two types of knowledge necessary for decision making--“how to” knowledge and “principal” knowledge. Similar to behavioral capability, “how to” knowledge is the awareness of what to do and how to do it. Neumann, et al. [1974] examined parents “how to” knowledge of age-appropriate restraining devices. A person’s skill development occurs with “how to” knowledge. “Principal knowledge” refers to the person’s understanding of how safety restraint devices work.

I. Knowledge -+ A

II.

Persuasion -+

III.

Adoption Decision -Confirmation Rejection A

I

Compatibility “How to”

Complexity

“Principal”

Trialability Relative Advantage Simplicity Fig. 7. Innovationdecisionprocess.

Iv.

36

G. D. NELSON and P. B. MOFFIT

The relative advantage, compatibility, simplicity. trialability, and observability of results are characteristics which enhance the adoption of safety belt use. Educational methods should be used which emphasize the relative advantage of safety belts over alternative methods of protection. The compatibility of safety belt use with one’s values of health, safety, or family and the simplicity of using restraints should be emphasized [Sweetser, 19671. The trialability or divisibility of safety belt use allows the individual to test the new behavior without threat of a long-term obligation. The simplicity or ease of safety belt use leads to continued maintenance of the behavior. For example, Jonah [1984] reported that effectiveness, comfort, and convenience were beliefs which strongly influenced seat belt use. The costs, whether financial, psychological, or amount of effort required, will also determine safety belt use. Finally, providing observable evidence of the benefits of safety belt use enhances a favorable assessment of the behavior. There are a number of immediate benefits of safety belt use which should be emphasized in educational programs. These include psychological benefits such as personal security, better child passenger behavior, and reinforcement of the safety belt behavior of others [Williams, 1972; Hoadley, Macrina, and Peterson, 1981; Morgan, 19671. SUMMARY

AND

CONCLUSIONS

The purpose of this paper was to review and recommend the use of selected theoretical appraoches in safety belt promotion programs. Application of theory represents a means to improve the effectiveness of safety belt programs. Six theoretical frameworks have been briefly described and applied to efforts to increase safety belt use. Practitioners are encouraged to use the references cited in this paper for a more thorough discussion of each theoretical framework. Granted, theory building is of interest to researchers and academicians, but ultimately, it is the practitioner and their clients who benefit from the use of theory. There are numerous factors to consider when applying theory to safety belt promotion programs. First, a theory is only as effective as its appropriate application. The identification of factors effecting individual use and nonuse should be matched with appropriate theoretical frameworks. Initiation and maintenance of safety belt use are distinct behaviors and responsive to possibly different theoretical approaches. Selection of a theoretical model should be based on empirical evidence of effectiveness. It is recommended that untested theoretical applications be pilot tested. The ethics of a theoretical approach may be a determining factor in selection. Theoretical approaches may differ with respect to the costs of application. Incorporation of any single theoretical framework should not be considered solely predictive of successful safety belt use. Each theoretical model should be viewed as helpful but alone not sufficient among various approaches promoting safety belt use. Combinations of theoretical appraoches that are simple to understand, easy to apply, appropriate for the setting, and previously demonstrated to be effective, may be most desirable.

REFERENCES Allen D. B. and Bergman A. B., Social learning approaches to health education: Utilization of infant auto restraint devices. Pediatrics 58: 323-328, 1976. Aronson E., The Socral Animal. W. H. Freeman & Company, San Francisco, 1980. Ajzen I. and Fishbein M., Understandmg Attrtudes and Predicting Behavior. Prenttce-Hall, Englewood Cliffs. NJ, 1980. Baker S. P. and Dietz P. E., Injury Prevention. In Healthy people: The surgeon general’s report on health promotion and dbease prevention, background papers. U.S. Dept. of Health, Education and Welfare. Public Health Service, Washington, DC. 1979. Bandura A., Social Learning Theory. Prentice-Hall, Englewood Cliffs, NJ, 1977a. Bandura A.. Social Foundations of Thought and Action. Prentice-Hall, Englewood Cliffs, NJ, 1986. Bandura A., Self-efficacy: Towarda umf$g theory of behavior change. P&ho1 Review 84: 191-215, 1977b. Baranowski T., A cognitive-emotional social learnmg theory approach to regimen compliance behavior. A paper presented to the annual Convention of the American Psychological Association, New York City. 1979. Beck K. H. and Frankell A., A conceptualization of threat communications and protective health behavior. Sot Psych Quart 44: 204-217, 1981.

Safety belt promotion

31

Becker M. H., Personal health behavior and the health belief model. Health Educ. Mong. 2: 324-329. 1974. Becker M. H. and Rosenstock I. M., Social-psychological research on determinants of preventive health behavior. In Kane R. L., (Ed.) The Behavioral Sciences and Preventrve Medicine. DHEW Pub. No. (NIH) 76-878, Washington, D.C., 1978. Becker M., Kasal S., Kxscht J., Maiman L. and Rosenstock I., Selected psychosocial models and correlates of individual health-related behaviors. Medical Care 15:27-46, 1977. Berkowitz L. and Cottingham D. R., The interest value and relevance of fear-arousing communications. J. Abnorm.

Sot. Psychol. 60: 37-43,

1960.

Caldwell P.. Thirty years of crash protection Safety 22-24,

tests prove that safety belts offer the best protection.

Traffic

1985.

Campbell B. J., Hunter W. W. and Stutts J. C., The use of economic incentives and education to modify safety belt use behavior of high school students. Health Educ 15:30-33, 1984. Centers for Disease Control, Morbidity and Mortality Weekly Report. U.S. Public Health Service, DHHS, 33: 1984. Christopherscn E. R., Preventing injuries to children: A behavioral approach to child passenger safety, In Matarazzo J. D., Weiss S. M., Herd J. A., Miller N. E. and Weiss S. M. (Eds.). Behavioral Health: A Handbook of Health Enhancement and Disease Prevention. John Wiley, New York, 1984. Chr&ophersen E. R. and Gyulay J. E., Parental compliance with car seat usage: A positive approach with long-term follow-up. J. Pedtatr. Psychol. 6: 301-312, 1981. Davis T. and Moffit P. B.. Hospitals and health promotion. Iowa Assoc HPERD Journal 14. 1982. Enksen M. P. and Glelen A. C., The application of health education principles to automobile child restraint programs. Health Educ. Q. 10:30-54, 1983. Fhaner G. and Hane M., Seatbelts: Factors influencing their use. A literature survey. Accid. Anal. and Prev. 5: 27-43,

1973.

Fhaner G. and Hane M.. Seat belts: Relations between beliefs, attitude and use. J. Applied Psycho1 59: 472482, 1974.

Fhaner G. and Hane M., Seat belts: Changing usage by changing behefs, J. Appl. Psychol. 60: 589-598,197s. Fishbein M., Attitude and the prediction of behavior. Jn Fishbein M., (Ed.), Readings m Attitude Theory and Measuremenr. John Wiley, New York, 417-492, 1961. Fishbein M. and Alzen I., Belief, Attitude, Znrention and Behavior: An Introduction to Theory and Research. Addison Wesley, Reading, Mass. 1975. Fourteen States Mandate Seat Belts. Center 3: 17, 1985. Geller E. S., Corporate Incentives for Promoting Safety Belt Use: Rationale, Guidelines, and Examples. Contract DTNH 22-82-P-0552, National Highway Traffic Safety Administration, Department of Transportation, Washington, DC, 1982. Geller E. S. and Bigelow B. E., Development of Corporate incentive programs for motivating safety belt use: A review. Proceedings of the Third Symposium on Traffic Safety Effectiveness (Impact) Evaluation Projects. National Safety Council, Chicago, IL, 1983. Geller E. S., Davis L. and Spacer K., Industry-based incentives for promoting seat belt use: Differential impact on which collar versus blue collar employees. J. Organ. Beh. Management 5: 17-29, 1983. Geller E. S. and Hahn H. A., Promoting safety belt use at industrial sites: An effective program for blue collar employees. Professional Psychology: Research and Practice, 1983. Geller E. S.. Johnson R. P., and Pelton S. L., Community-based interventions for encouraging safety belt use. Am. J. Community Psychol. 10:183-195, 1982. Geller E. S., Paterson L. and Talbott E., A behavioral analysis of incentive prompts for motivating seat belt use. J. Appl. Behav. Anal. 15:403-415, 1982. Gielen A. C., Ericksen M. P , Daltroy L. H. and Rost K., Factors associated with the use of child restraint devices. Health Educ. Q. 11:195-206,1984. Goldbaum G. M., Remington P. L.. Powell K. E , Hogelin G. C., and Gentry E. M., Failure to Use Seat Belts in the United States, JAMA 255: 2459-2462. 1986. Green L., Kreuter M., Deeds S. and Partridge K., ‘Health Education Planning: A Dlagnostlc Approach. Mayfield Publishing, Palo Alto, CA. 1980. Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention. Publication No. 79-55071, U.S. Department of Health Education and Welfare, Public Health Service, Washington, DC, 1979. Health Education Monographs

6: 1978.

Helsing K. J. and Comstock G. W., What kinds of people do not use seat belts. Am. J. Public Health 67: 1043-1050, 1977. Higbee K. L., Fifteen years of fear arousal: Research on threat appeals: 1953-1968. Psych. Bull. 72: 426444, 1969.

Hoadley M. R.. Macrina D. M. and Peterson F. L., Child safety programs: Implications affecting use of child restraints. J. Sch. Health 51:352-355, 1981. Hoadley M. R., Struckman-Johnson C. and Osgood R. K., Attitudes in rural communities toward restraint devices and loan programs. Health Educ. 15:54-56, 1984. Insurance Institute f&r Highway Safety, Crash tests do show how belted drivers will fare m actual colhsions. Status Report 20: 1, 4, 1985a. Insurance Institute for Highway Safety, Dole puts certification of belt use laws on hold until court decides case. Status Report 20: 1985b. Jonah B. A., Dawson N. E. and Smith G. A., Evaluation of the effects of a selective traffic enforcement program on seat belt usage. Technical Memorandum 8001. Human System Division, Ottowa, Canada, 1980. Jonah B. A. and Dawson N. E., Predicting reported seat belt use from attitudinal and normative factors. Accid

Anal. and Prev. 14: 305-309,

1982.

Jonah B. A. and Lawson J. J., The effectiveness of the Canadian mandatory seat belt use laws. Acctd. Anal. and Prev. 16: 433-450.

1984.

38

G. D. NELSON and P. B. MOFF~I-

Jonah B. A., Legislation and the prediction of reported seat belt use. J. Appbed Psychol. 69: 401-407. 1984. Kerlinger F. N.. Foundations of Behavioral Research. Holt, Rinehart and Winston: New York, 1973 King K., Selected behavioral strategies for the health educator. Health Educ. 13: 35-37, 1982. Knapper C. K., Cropley A. J., and Moore R. .I., Attitudinal factors in the non-use of seat belts. Accid. Anal. and Prev. 8: 241-246, 1976. Lawson D., Sleet D. H., and Amom M., Prloritles for motor vehicle occupant protection among chiidren and youth. Health Educ 15: 27-29. 1984. Leventhal H., Findings and theory in the study of fear communications. In Berkowitz L.. (Ed.), Adv. Exp. Sot. Psychol. 5: 119-186, Academic Press: New York. 1970. Leventhal H., Fear appeals and persuasion: The differentiation of a motlvational construct. Am. J. Pubhc Health 61: 1208-1224, 1971. Loo R.. Correlates of reported attitude towards and use of seat belts. Accrd. Anal. and Prev. 16: 417-421, 1984. Mahoney M.. Thoresen, Seat belt use in Ontario four years after mandating legislation. Accid. Anal. and Prev. 14: 431-438, 1982 McGuire W J., Nature of attitudes and attitude change. In G. Lindsey & E. Aronson (Eds ), The Handbook of Social Psychology 3: 136-314. Addison-Wesley: Reading, MA. I969 McKnight J. and McPherson K.. Four Approaches to Instruction in Occupant Restraint Use. Transportatton Research Record 844: Automotive Tkchnology Information Needs Highway users. and Promotion of Safetv Belt Usage, Washington. DC: Transoortation Research Board, National Research Council, National Acadkmy of Scknces. 1982. Moffit P. B., Effects of a child restraint education and loan program on restraint use. Doctoral Dissertation. University UT, 1981 Moffit P. B., Motor vehicle restraint legislation: A remaining need for health education. Iowa Assoc. HPERD Journal 18:4-6, 1985 Moffit P. B. and Nelson G. D., Effects of varymg levels of fear arousal on opinions regarding mandatory safety belt use laws. Unpublished manuscript, 1986. Morgan J. N., Who uses seat belts? Behav. Sci. 12: 463-465. 1967. National HIghway Traffic Safety Administration, The Profit in Safety Belts: An Introduction to an Employer’s . Program- U.S. Government Printing Office, DOT HS 806-452: Washington, DC 1984. National Hiehwav Traffic Safetv Administration. The Economic Cost to Socien, for Motor Vehicle Accrdents. U.S. Dept. oi Transportatidn, DOT HS 806-342, Washington, DC, 1983. . ’ Nelson G. D., and Bruess C., Assessment of a worksite safety belt program. Health Educ. 17: 63-67. 1986. Neuman C. G.. Neuman A. K., Cockrell M. E. and Banani S., Factors associated with child use of automobile restraining devices: Knowledge. attitudes and practice. Am. J. Dis. Child. 128: 469-474. 1974. Nichols J. L., The safety potential of safety belts, child restraints, and programs to promote their use. (Serial No. 97-141, 398-513). National Highway Traffic Safety Administration, Washington, DC, 1982. O’Neill B., After mandatory use laws: Future approaches to decreasing highway fatalities, Focal Points 3: X9, 1986. Page R. M., Seatbelt use among preadolescent children: Implications for school health education. Health Educ. 15:35-38. 1984. Parcel G. S., Theoretical models for application in school health education research. Health Educ 54: 3Y49, 1983. Parcel G. S., and Baranowski T., Social learning theory and health education. Health Educ. l2: 14-18. 1981. Promotina Health/Preventing Disease: Obiectlves for the Nation. U.S. Department of Health and Human Servic&, Public Health Grvice, Washington DC, 1980. Reichelderfer T. E.. A first orioritv-child automobile safetv. Pediatrics 58: 307-308. 1976. Robertson L. S., O’Neill B.’ and hixon C W., Factors associated with observed safety belt use. J. Health Sot. Behav. 13: 18-24, 1972. Rogers E. M.. and Shoemaker F. F., Communrcatron of Innovations. Free Press: New York, 1971 Rosenstock I. M., Historical origins of the Health Belief Model. Health Educ. Mongr. 2: 328-335. 1974. Rotter J. B., Social Leurning and Clinical Psychology. Prentice-Hall: Englewood Cliffs, NJ, 1954. Russel G. W., Bulloci J. L., and Corenblum B. S. Personality correlates of concrete and symbolic precautionary behaviors. Inter. Review of Appl. Psychol. 26: 51-57, 1977. Schawlm N. D. and Slavic P. Development and test of a motivational approach for increasing use of restraints. Perceptronics. Inc. Final report. National Highway Traffic Safety Administration. U.S. Department of Transportation, Washington, DC DTNH22-80-C-07505, 1982. Sheard J. G., Kane W. M. and Dane J. K., Occupant protection programs in industry: Driving toward the bottom line. Health Educ 15:38-43, 1984. Skinner B. F., The Behavior of Organisms. Appleton-Century-Croffts, NY, 1938. Sleet D. A. and Geller E. S., Do incentive programs for safety belt use work? Focal Potnts 3: l-2. 1986. Sleet D. A., Seat belt motivation: Modifying behavior with incentives. Industrial Safety and Hygiene 18: 1984. Suchman E. A.. Evaluating educational programs: A symposium. Urban Review 3: 1969. Sutton S. R., Can subjective expected utility (SEU) theory explain smokers’ decisions to try to stop smoking? In D. J. Oborne, M. M. Gruneberg, &J. R. Eiser (Eds.), Research in Psychology and Medicine. Academic Press: London, 1979. Sutton S. R.. The effect of fear arousing communications on cigarette smoking: An expectancy-value approach. J. Behav. Med. 7: 13-33, 1984. Sweetser. D. A.. Attitudinal and social factors associated with use of seat belts. J. Health Sot. Behav. 8: 116125, i967. Tarrance and Associates, Motives of restramt system usage among specific target groups of drivers and passengers, NHTSA, Contract #DTNH22-82-C-07184, 1982. Wallston K. A., Health locus of control. Patient Education Newsletter 56-57, 1982. Wilhams A. F., Factors associated with seat belt use in families. J. Safety Res. 4: 133-138, 1972.

of