Unbelted Occupants

Description of Strategies

Objectives

Three objectives were identified for the occupant restraint area:

1. Initiate programs to maximize use of occupant restraints by all vehicle occupants;
2. Ensure that restraints for children of all ages are properly used; and
3. Provide access to appropriate information, materials, and guidelines for those implementing programs to increase occupant restraint use.

The intent of these objectives is to enable primarily local and regional entities, but also entire states, to implement programs to increase use of restraints and to ensure that those systems are properly used. Restraint use for adults varies across the states from just over 55 percent (Massachusetts) to more than 90 percent (California, Hawaii, and Washington). Many studies have been done on the effectiveness of occupant restraints, and they continue to show that vehicle occupants are about 50 percent more likely to be hospitalized from crash-related injuries if they were not wearing a seatbelt at the time of the crash (Boyle and Sharp, 1997a, 1997c).

Targeted programs to increase restraint usage have been proven effective. Localities in some states have implemented programs that have increased local restraint use by 20 to 30 percentage points over statewide averages at the start of their program. Entire states also have implemented similar programs. Exhibit V-1 shows the restraint usage increases attained by states after implementation of the “Click It or Ticket” program throughout each of those states. Details of the “Click it or Ticket” campaign can be found later in this section or check the Web site.

Even North Carolina, which is a primary enforcement state and which has one of the highest use rates in the country, was able to increase use another 4 percent during this campaign.

EXHIBIT V-1
Click It or Ticket Seatbelt Use Rate Increases

The average increase in belt usage during other state programs was almost 10 percent. The key to the campaign was a combination of enforcement and public information and education on a statewide basis.

However, even a secondary enforcement state can achieve significant increases in usage. Montana has increased their rate to 75 percent through efforts of education and increased attention to enforcing the seatbelt law in conjunction with standard traffic enforcement at the community level.¹

The combination of enforcement and public information campaigns appears to be the key to achieving meaningful, lasting increases in restraint usage. Recent studies by the IIHS (Insurance Institute for Highway Safety, 2001) show that public education efforts alone, without an enforcement component as demonstrated in Montana, are generally not successful.

The objectives are listed in Exhibit V-2, along with a series of strategies recommended for achieving them.

EXHIBIT V-2
Emphasis Area Objectives and Strategies

Objectives	Strategies
8.1 A Maximize use of occupant restraints by all vehicle occupants	8.1 A1 Conduct highly publicized enforcement campaigns to maximize restraint use. (P) 8.1 A2 Provide enhanced public education to population groups with lower than average restraint use rates. (P) 8.1 A3 Encourage the enactment of local laws that will permit standard enforcement of restraint laws. (T)
8.1 B Insure that restraints, especially child and infant restraints, are properly used	8.1 B1 Provide community locations for instruction in proper child restraint use, including both public safety agencies and health care providers, that are almost always available. (T) 8.1 B2 Conduct high-profile “child restraint inspection” events at multiple community locations. (P) 8.1 B3 Train law enforcement personnel to check for proper child restraint use in all motorist encounters. (T)
8.1.C Provide access to appropriate information, materials, and guidelines for those implementing programs to increase occupant restraint use	8.1.C1 Create state-level clearing houses for materials that offer guidance in implementing programs to increase restraint use. (E)
P = proven; T = tried; E = experimental

Explanation of Strategy Types

The strategies in this guide were identified from a number of sources, including a literature review, contact with state and local agencies throughout the United States, and federal programs. Some of the strategies are widely used, while others are used at a state or even a local level. Some have been subjected to well-designed evaluations to prove their effectiveness. However, it was found that many strategies have not been adequately evaluated, including some widely used strategies.

The implication of the widely varying experience with these strategies, as well as the range of knowledge about their effectiveness, is that the reader should be cautious before adopting a particular strategy for implementation. To assist, the strategies have been classified into three types, each identified by letter throughout the guide:

• Proven (P): Those strategies that have been used in one or more locations and subjected to properly designed evaluations that show it to be effective. These strategies may be employed with a good degree of confidence, but any application can lead to results that vary significantly from those found in previous evaluations. The attributes of the provided strategies will help the user to judge the most appropriate for his or her particular situation.
• Tried (T): Those strategies that have been implemented in a number of locations and that may even be accepted as standards or standard approaches, but that lack found valid evaluations. These strategies, while in frequent or even general use, should be applied with caution, carefully considering the attributes cited in the guide and relating them to the specific conditions for which they are being considered. Implementation can proceed with some degree of assurance that a negative impact on safety is unlikely and that a positive one is very likely. It is intended that appropriate evaluations can be conducted as the experiences implementing these strategies continue under the AASHTO Strategic Highway Safety Plan (SHSP) initiative. In this matter, effectiveness information can be accumulated to provide the user with better estimating power and to upgrade the strategy to “proven.”
• Experimental (E): Those strategies that have been suggested and found sufficiently promising that at least one agency has considered trying them on a small scale in at least one location. These strategies should be considered only after the others have proven inappropriate or unfeasible. Even where they are considered, their implementation should initially occur using a very controlled and limited pilot study that includes a properly designed evaluation component. Broader implementation should be considered only after careful testing and evaluations show the strategy to be effective. It is intended that as the experiences of such pilot tests are accumulated from various state and local agencies, the aggregate experience can be used to further detail the attributes of this type of strategy so that it can be upgraded to “proven.”

Targeting the Objectives

The objectives presented here are intended for a variety of target audiences. Implementation will best be done by local or regional community coalitions, although local law enforcement could carry out some strategies on their own.

The first strategy for the first objective must have law enforcement involvement, since it is focused on law enforcement. The second strategy can be implemented by law enforcement or any other interested group, although law enforcement should be involved. The final strategy under the first objective need not directly involve law enforcement, since it involves enactment of local law.

The first two strategies for the second objective can involve any community-based entity, including law enforcement. The key for both strategies is having individuals and facilities available in the community. The final strategy there relates strictly to law enforcement.

The final objective is focused at the state level. While a state DOT could be the enabling entity, other organizations, both governmental and nongovernmental, could provide the action recommended.

Related Strategies for Creating a Truly Comprehensive Approach

It is recommended that related strategies be included as candidates in any program planning process to create a truly comprehensive approach to the highway safety problems associated with this emphasis area. In fact, the effort to increase the use of seatbelts will be a compatible concomitant effort with just about any of the strategies recommended for any of the emphasis areas included in the AASHTO Strategic Highway Safety Plan.

Two basic types of strategies are emphasized in the above objectives: enforcement and public information and education. However, there are others that should be taken into general consideration as important to be functioning along with those specified for this particular emphasis area.

• Strategies to Improve Emergency Medical and Trauma System Services: Treatment of injured parties at highway crashes can have a significant impact on the level of severity and length of time that an individual spends in treatment. This is especially true when it comes to timely and appropriate treatment of severely injured persons. Thus, a basic part of a highway safety infrastructure is a well—based and comprehensive emergency care program. While the types of strategies that are included here are often thought of as simply support services, they can be critical to the success of a comprehensive highway safety program. Therefore, for this emphasis area, an effort should be made to determine if there are improvements that can be made to this aspect of the system, especially for programs that are focused upon location—specific (e.g., corridors) or area—specific (e.g., rural areas) issues. As additional guides are completed for the AASHTO Plan, they may address the details regarding the design and implementation of emergency medical systems strategies. When that occurs, the appropriate links will be added from this emphasis area guide.

• Strategies Directed at Improving the Safety Management System: The management of the highway safety system is foundational to success. There should be in place a sound organizational structure—well as an infrastructure of laws, policies, etc.—to monitor, control, direct, and administer a comprehensive approach to highway safety. It is important that a comprehensive program not be limited to one jurisdiction, such as a state DOT. Local agencies often have the majority of the road system and its related safety problems to deal with. They also know, better than others do, what the problems are. As additional guides are completed for the AASHTO Plan, they may address the details regarding the design and implementation of strategies for improving safety management systems. When that occurs, the appropriate links will be added from this emphasis area guide.

Objective 8.1 A—Maximize Use of Occupant Restraints by All Vehicle Occupants

Strategy 8.1 A1: Conduct Highly Publicized Enforcement Campaigns to Maximize Restraint Use

Enactment of mandatory restraint laws has increased restraint use substantially in every state in which they were passed. In addition, when states have replaced secondary enforcement laws with standard enforcement, restraint use again increases.² Though laws themselves increase use, it is the addition of promised enforcement that increases seatbelt use.

Whether a state has standard or secondary enforcement, seatbelt laws, highly publicized enforcement campaigns, along with public information and education, have been shown to be effective in increasing restraint use. While restraint-use levels reached during such campaigns usually drop off after the campaign ends, they tend to remain above precampaign levels. The model for this type of campaign was developed by the State of North Carolina in its “Click it or Ticket”³ program. It has been successfully copied by several other states. Nearly every law enforcement agency in these states has participated in “Click it or Ticket.” Since the start of the North Carolina program, law enforcement officers have operated nearly 30,000 checkpoints and issued more than 200,000 seatbelt and 18,000 child safety seat citations. North Carolina media outlets of all kinds provided materials to alert citizens about the program. Before “Click it or Ticket” began in 1993, about 65 percent of North Carolinians buckled up. Restraint use has climbed to 84 percent, one of the higher rates in the nation. Since “Click it or Ticket” began in 1993, fatal and serious highway injuries in North Carolina have been cut by 14 percent. The result: a savings of at least $135 million in health-care-related costs. While not all the improvement in the State's crash experience can be credited to increased restraint use, it certainly seems to have played a major role.

While standard enforcement states have an advantage, in that officers can stop vehicles for only that violation, enforcement can be effective in states with only secondary enforcement laws. Montana has demonstrated that a good community program with active support from law enforcement can achieve high rates of use. From very low percentages, usage has risen for the state as a whole to 78 percent.⁴ This was done by energizing communities to support a program designed to increase seatbelt use.

Increasing use of occupant restraints is a low-cost strategy in comparison with others. The primary restraint, the lap/shoulder belt, exists in every post-1964 vehicle. Child/infant seats or boosters cost less than $100 and are available at no cost or reduced cost to many users. The cost of implementing most of these strategies lies in getting people to properly use those restraints that are available to them.

Past traffic-law-related programs, particularly in the impaired driving area, have shown that law “crackdowns,” without accompanying publicity, are ineffective in improving compliance with the law (even though arrest rates might increase). Although similar programs have not been reported where enforcement of restraint use was not accompanied by public information and education, comparable lack of effectiveness would be expected in the seatbelt area. Similarly, recent studies have shown that public information and education, without accompanying enforcement, have not been as effective.

Therefore, the strategy proposed here is to implement enforcement that is made effective through carefully coordinated public-information and education campaigns designed to maximize occupant-restraint usage. These programs can be implemented on either statewide or local levels. Care must be taken, however, to ensure that a form of “profiling” is not being used to target members of a particular group for increased police enforcement. Rather, it must be emphasized that the intent of the program is to protect members of the community by both increasing their safety and, by increasing compliance with the law, reducing the chances that members of the group will be stopped by law enforcement.

EXHIBIT V-3
Strategy Attributes for Conducting Highly Publicized Enforcement Campaigns to Maximize Restraint Use

Attribute	Description
Target	The driving population that does not routinely use occupant restraints.
Expected Effectiveness	Various combined enforcement and public information and education (PI&E) campaigns have shown that this strategy can substantially increase restraint usage. Studies have also shown that these two elements must be used in combination. PI&E without enforcement has not shown sustained increases in restraint usage. The effectiveness of increased seatbelt and restraint device usage has been generally estimated by NHTSA (see the section on the type of problem being addressed). Therefore, success and effectiveness are usually measured in terms of the surrogate measure of increased usage. Examples of successful campaigns include the following: Click It or Ticket (North Carolina) Buckle Up NOW! (Elmira, New York) Making it Click in Michigan
Keys to Success	The primary key to success is to combine the enforcement and PI&E efforts. The successful campaigns referred to here publicized the campaign heavily, in a mix of media, and then made sure that enforcement efforts were as visible as possible, as well as being well reported in the media. Strong cooperative agreements are also needed if more than one agency/entity is going to participate in the event. All law enforcement agencies operating in the area must agree to participate in the project.
Potential Difficulties	Unwillingness of media to assist in getting the campaign message out and/or not reporting on enforcement efforts. Lack of priority by all officers in the law enforcement agencies. Reluctance of courts to sanction the citations for failure to wear seatbelts in secondary enforcement states.
Appropriate Measures and Data	The primary measure of effectiveness will be the change in severity of crashes. However, the effect of restraint—use campaigns can be difficult to separate from other concomitant factors. Therefore, the change in the percentage of people observed to be using seatbelts is a popular surrogate. Process measures can include the following: Number of citations issued for not wearing seatbelts or using child restraints PI&E airtime and/or column-inches of print reporting Police officer time on directed seatbelt enforcement patrol and/or checkpoints
Associated Needs	The need for a strong coordinated PI&E campaign may require the services of professionals with this expertise to design, prepare, implement, and monitor the program.
Organizational, Institutional, and Policy Issues	The primary organizational issue is referred to under “Key to Success” above—all relevant organizations must agree to participate in the project. The nature of the seatbelt laws in the project jurisdiction can raise policy issues, particularly if they have a secondary enforcement law. Two policy options to consider are whether to conduct general safety checkpoints where restraint use is among items checked and how agencies will handle double citations if traffic stops must be made initially for an offense other than failure to wear seatbelts.
Issues Affecting Implementation Time	The key here is to have one person with overall responsibility for the project. That individual should be able to keep all project components operating according to schedule. In addition, the time required to prepare materials for reaching the target community may take significant time, especially if those that are to do the job must be contracted with from outside the agency.
Costs Involved	There are two potential cost items here. The first is media production. Billboards and handouts are usually included in this type of campaign. Funding or donation agreements must be in place to meet these needs. Paid media is usually not needed for this type of project. The other cost consideration is overtime required for use of law enforcement personnel. If officers are to be brought back to staff checkpoints or conduct saturation patrols, arrangements will need to be in place to cover these salaries.
Training and Other Personnel Needs	Assuming public information personnel are already in place in the relevant agencies, no additional training should be needed to manage the PI&E aspect of the program. Law enforcement personnel should not need training in enforcing occupant restraint laws. However, officers may benefit from motivational messages delivered at such times as roll call.
Legislative Needs	Some improvements in state laws may be needed. For instance, while all states do have child passenger restraint laws, there is considerable variation among those laws. Some states have adopted what is considered a model law covering children or all ages in all seating positions, regardless of who owns or is operating the vehicle. Other states have less satisfactory laws that do not cover all ages or seating positions, or exempt nonparent drivers from the law. For an analysis of child passenger restraint laws in the United States see http://www.highwaysafety.org/safety_facts/state_laws/restrain.htm. Guidelines for a model law may be found at http://www.carseat.org/Legal/637_Guide_ CPSlaw.pdf and http://www.safekids.org/tier3_cd.cfm?content_item_id=831&folder_id=183 The highly regarded law for California is summarized at http://www.carseat.org/Legal/6_sum_CA_Law.pdf The need for local laws is addressed in Strategy 8.1 A3

Strategy 8.1 A2: Provide Enhanced Public Education to Population Groups with Lower than Average Restraint Use Rates

The preceding strategy is focused on increasing occupant restraint usage generally. Here, the focus is on specific population groups that have lower than average restraint usage. These groups can be defined by socioeconomic status, race, ethnicity, age, sex, locale, or any other factor that can be used to define a population of people.

For example, it was well documented that seatbelt and child restraint use is lowest among persons of lowest socioeconomic status (Campbell and Campbell, 1986). The 2000 update of The Use of Safety Restraint Systems in Virginia by Occupants Under 16 Years of Age: The 2000 Survey Results (Stoke, 2001) recommended that bolstered efforts be directed at smaller communities and rural areas and at occupants of rear seating in that state because of low rates of use observed. In a study by Lerner et al. (2001), the demographic factors associated with reported seatbelt use included age, gender, race, and income. NHTSA reported that in 2002 overall seatbelt use was 75 percent, but the last seatbelt use rate recorded for Hispanics was 63 percent (Glassbrenner, 2002).

The general approach for this strategy is similar to that of the first strategy. It is assumed that local at-risk populations have been identified, either by local observations or analysis of available crash-related data, or that local populations mirror documented national trends. However, before a campaign is launched, the population group to be targeted is approached. Meetings are held with key leaders in the target communities to discuss the campaign and its impact on these communities. These meetings provide an opportunity to gain feedback and to assess reactions to the proposed programs. In most cases, the communities with lower than average restraint use rates have higher than average traffic fatality rates. The proposed campaign seeks to gain support from population group leaders prior to implementation by specifically emphasizing that the ultimate goals of the campaign are to reduce death and injury rates within that group. The most successful model for such a campaign was implemented in South Carolina (see http://www.nhtsa.dot.gov/people/injury/airbags/Archive-04/Click%20It%20Web/index.html).

An additional example of an ongoing program directed toward both students in high schools and senior citizens has been underway in Jefferson County, Wisconsin. The activity is part of the Jefferson County Safe Communities Coalition also called “Stop Crashes.” Their material can be found at http://www.stopcrashes.com/.

Other examples of campaigns and materials of this type include the following:

• Seat Belts and African Americans, http://www.nhtsa.dot.gov/people/outreach/safesobr/22qp/seatbelt_fact_sheets/seatbelts_afr_amer.html

• Seat Belts and Hispanics, http://www.nhtsa.dot.gov/people/injury/airbags/buckleplan/seatbeltshispanic/index.htm

• “Conoce la Realidad o Sufre las Consecuencias” (“Know the Facts or Suffer the Consequences”) http://www.nhtsa.dot.gov/people/injury/airbags/Archive-04/Know%20the%20Facts%20web/

EXHIBIT V-4
Strategy Attributes for Providing Enhanced Public Education to Population Groups with Lower than Average Restraint Use Rates

Attribute	Description
Target	Members of population groups (geographical, ethnic, age, gender, race, etc.) whose restraint use is lower than average.
Expected Effectiveness	The effectiveness of increased seat belt and restraint device usage has been generally estimated by NHTSA (see Section III, Type of Problem Being Addressed). Therefore, success and effectiveness are usually measured in terms of the surrogate measure of increased usage. The program in South Carolina, however, provided the following results: “Safety belt use rates improved dramatically, particularly among the nonwhite population. Overall usage rates increased from 65.5 percent to 73.9 percent. Nonwhite use rates increased from 56.1 percent to 70.4 percent, an astounding 14.3 percentage points. Seatbelt use among males increased from 59.2 percent to 67.9 percent, an increase of 11.5 percent. There was a 29.5-percent decrease in fatalities (31 deaths in 2000 compared to 44 fatalities during the same period in 1999).” The Jefferson County (Wisconsin) Safe Communities Coalition has been able to achieve more than 87-percent usage in selected populations. This has occurred in a state that has a secondary enforcement law.
Keys to Success	The primary key to success is to verify that the group/community being targeted does have below average restraint use rates. This can be done through local surveys or observations (or at least informal observations to confirm local conformance to national use rates). It is also important to have a “champion” from within the group/community toward which the campaign will be directed. This will both give the effort credibility and provide guidance in focusing materials, appropriate media, and message.
Potential Difficulties	The group/community toward which the campaign is being directed must be assured that they will not be targets of police profiling or otherwise be singled out for extra enforcement or other special law enforcement attention.
Appropriate Measures and Data	The primary measure of effectiveness will be a change in restraint usage by members of the group/community toward whom the campaign is directed. This is a surrogate for change in crash severity. Observational surveys of seatbelt usage may be done before and after implementing the program. Process measures can include the following: PI&E airtime and/or column-inches of print reporting Police officer time on directed seatbelt enforcement patrol and/or checkpoints Number of citations issued for not wearing seatbelts
Associated Needs	Accurate surveys and/or observations are needed to identify the groups/communities that are below average in restraint use.
Organizational, Institutional, and Policy Issues	The primary organizational issue is referred to under “Keys to Success” above—the need to identify and involve a “champion” from within the targeted group. In addition, mechanisms are needed to encourage members of the group, and other stakeholders, to participate in all stages of the effort, from planning through implementation. TA policy issue will be to ensure that law enforcement does not focus on the group targeted by the campaign. Believing that they might have been “set up” for increased law enforcement contacts could seriously damage the hoped-for effect of the message and the credibility of the entity working to increase restraint use in that community.
Issues Affecting Implementation Time	The key here is to have one person with overall responsibility for the project. That individual should be able to keep all project components operating according to schedule. In addition, the time required to prepare materials for reaching the target community may take significant time, especially if those that are to do the job must be contracted with from outside the agency..
Costs Involved	The primary costs for this strategy are media production, as well as costs associated with making presentations to targeted groups and organizations. Billboards, public service announcements, and handouts are usually included in this type of campaign. Funding or donation agreements must be in place to meet these needs. Paid media is usually not needed for this type of project. If seatbelt use surveys or observations need to be paid for, that would represent an additional significant cost.
Training and Other Personnel Needs	Assuming public information personnel are already in place in the relevant agencies, no additional training should be needed. However, officers may benefit from motivational messages, as well as cautions against the use of profiling, delivered at such times as roll call.
Legislative Needs	There do not appear to be any special legislative needs for this strategy.

Strategy 8.1 A3: Encourage the Enactment of Local Laws That Will Permit Standard Enforcement of Restraint Laws

In many states, the legislature has been very reluctant to change the law from secondary to standard enforcement. It is more desirable to enact standard enforcement occupant laws on the state level, if at all possible. The reluctance to do so is present, even though studies show that restraint use is high with standard (or primary) enforcement; see Exhibit V-5. For organizations that are interested in trying to enact such state-level laws, resources are available. See http://www.nhtsa.dot.gov/people/injury/airbags/model/safetybeltlaw.html, and http://www.nhtsa.dot.gov/people/injury/airbags/buckleplan/enforceseatbeltlaws/index.html.

EXHIBIT V-5
Seatbelt Use Rate by Enforcement Type
Source: National Highway Traffic Safety Administration, 1999.

However, in some of these states, communities have passed local laws (ordinances), permitting standard enforcement in that jurisdiction. These efforts have been upheld by the courts in these states and are a means of increasing local restraint usage.

An example of a local ordinance is given in Appendix 1.

Enactment of this strategy is usually a two-stage process. First, the local authorities need to be convinced to pass an appropriate ordinance. A local coalition of individuals and/or organizations concerned with traffic safety is a good example of the mechanism through which this might be accomplished. Then, the local ordinance must be publicized, the local enforcement agency must enforce it, and the courts must apply appropriate sanctions. The publicity for the law usually includes posting notice of the law on main routes into the community so that nonresidents are aware that standard enforcement of the law is permitted there. In some cases, the courts have required such posting.

The key to implementing this strategy is to seek out communities that have police chiefs and senior law enforcement officials who strongly support seatbelt law enforcement. It is also important to research the trends in those communities' legislative bodies to see if they have passed other ordinances dealing with public safety and health issues and, if they have, become informed of how much these preventable injuries were costing their communities. It is also important to know if they have shown a willingness to go beyond other state laws to improve safety and quality of life.

EXHIBIT V-6
Strategy Attributes for Encouraging the Enactment of Local Laws That Will Permit Standard Enforcement of Restraint Laws

Attribute	Description
Target	Communities in states that do not have standard enforcement mandatory occupant restraint usage laws.
Expected Effectiveness	Surveys of restraint usage consistently show that use is greater in states with standard enforcement than those with secondary enforcement (see Exhibit V-5). Since many state legislatures have not been willing to enact standard enforcement laws, cities and other municipalities can enact local legislation (ordinances) to permit standard enforcement within their jurisdiction. It is anticipated that restraint usage within these standard enforcement communities would exceed the state average. Although no formal research has been done in this area, one community with such a local ordinance (Lincolnshire, Illinois) reports restraint usage at 80 percent on arterial roads and 88 percent on local roads, compared to 71-percent statewide average usage.
Keys to Success	The primary key to success is for an advocate within the community to encourage the local government to enact standard enforcement legislation. This advocacy can come from within the government (police, emergency medical services [EMS], public health) or a citizen-based organization or coalition (emergency nurses association, local safety committee, etc.). In addition, stakeholders should be involved in the planning and implementation efforts for related programs to institute the law.
Potential Difficulties	State law must permit such local initiatives. Local government must be willing to take a highly visible position on such an issue.
Appropriate Measures and Data	The process measures include whether or not the local unit of government enacts a standard enforcement ordinance, measures of targeted enforcement activity, measures of PI&E efforts, measure of conviction success, and a measure of sanctions applied. Subsequent impact evaluation would look at changes in occupant restraint use rates after the standard enforcement ordinance is enacted, with accompanying public education and visible enforcement, etc.
Associated Needs	Accurate surveys and/or observations are needed to show local restraint use before and after the ordinance is enacted and in comparison to statewide averages.
Organizational, Institutional, and Policy Issues	An advocacy group within the community generally must encourage enactment of the local standard enforcement law, and the local unit of government must be willing to enact such relatively high-profile legislation. A mechanism is needed for stakeholders to be involved throughout the process in a meaningful way.
Issues Affecting Implementation Time	A significant amount of time may be required to convince the appropriate legislators that a law is needed. Once the law is passed, there will be a period required for the law enforcement agency to initiate targeted enforcement and time needed to mount a PI&E campaign. This could take at least 6 months after a law is passed, depending upon availability of personnel and budget.
Costs Involved	Possible significant cost elements include the conduct and analysis of seatbelt use surveys, special enforcement efforts, and PI&E programs.
Training and Other Personnel Needs	An information campaign that targets legislators and their constituents, as well as the judiciary, may facilitate the adoption of the law.
Legislative Needs	The goal of the strategy is to pass local legislation. However, state statutes must permit local units of government to enact such laws.

Objective 8.1 B—Insure That Restraints, Especially Child and Infant Restraints, Are Properly Used

Strategy 8.1 B1: Provide Community Locations for Instruction in Proper Child Restraint Use

A study by the National Transportation Safety Board (NTSB)⁵ showed that 62 percent of child and infant seats are not used properly. The most common types of misuse are the following:

• Not properly securing the child seat to the vehicle

• Placing child seats, particularly rear-facing infant carriers, in front seats where they can be struck by inflating airbags

• Improperly securing the child in the restraint device

In most cases these are errors of ignorance. Parents and others assume they are properly securing their children only to find that they have possibly placed the child at even greater risk of injury by not using safety devices properly.

To implement this strategy, communities need to identify and develop facilities that are generally available where individuals can drive in with their child and restraint device and have it checked for proper use. Such facilities might include fire stations, public health facilities, driver's license offices, vehicle emissions testing stations, etc. Individuals should be available during a large portion of the day (e.g., 8:00 or 9:00 a.m. to 7:00 or 8:00 p.m.) to do the inspections. For an example of insurance industry support for a regional program in Canada, see: http://www.mpi.mb.ca/english/rd_safety/kidsafe/free_seat_checks.html.

There also needs to be a continuing public information campaign to let individuals know that such a facility is available and that it is needed due to high device misuse rates. For a discussion of the appropriateness of materials concerning the use of child safety devices, see http://www.aaafoundation.org/projects/index.cfm?button=seated4safety and http://www.cpsboard.org/.

The city of Lodi, California, recently has begun a more active program to encourage proper use of child restraints. It is run by the police department but makes active use of the “Partners” organization, a group of retired persons that volunteer time to the department. This group has, along with the police, provided active, publicized inspection sites (see http://www.lodi.gov/police/btb/btb%20carseats%202.htm).

EXHIBIT V-7
Strategy Attributes for Providing Community Locations for Instruction in Proper Child Restraint Use

Attribute	Description
Target	Parents and others desiring to ensure child safety and booster seats are properly used.
Expected Effectiveness	The effectiveness of this strategy has not been documented. With resources available for checking correct use of child safety and booster seats, the percent of incorrectly used seats in a community would be expected to decrease. Publicity about the inspection stations should also encourage the general population of child safety seat users to become more aware of improper use and result in their being more likely to check for proper use on their own.
Keys to Success	The primary key to success is for entities to agree to host inspection stations that are open on a regularly scheduled basis and at times and locations convenient for child safety seat users. Relevant agencies in the community (police, EMS, public health) must be willing to supply certified inspectors to staff the stations, or a sufficient number of qualified citizen volunteers must be recruited for the staffing. Lodi, California, has an active police “partners” program, in which the participants become trained as trainers and then train others within the city. Their goal is to be able to train police, fire, and other partners to allow for the following: Multiple inspection sites Open locations, such as firehouses, for walk-in inspections Training police officers when making a traffic stop or other motorist contact to recognize incorrect usage (contact: Chris Jacobson at CJacobson@pd.lodi.gov)
Potential Difficulties	There may be difficulty finding appropriate locations to attract potential users. Care should also be taken to assure those that come to the centers that no enforcement action would be taken in conjunction with the visit, even if there has been improper use of the device in the past.
Appropriate Measures and Data	Process measures include the number of seats inspected, the number of sites, and the number of inspectors involved. The site—hours and/or inspector—hours of service and the number and percent of incorrect usages are identified and corrected. Without actually doing a hands-on inspection of the child safety seat with a child in it, it is hard to determine if the seat is being properly used. Therefore, it is difficult to use strictly observational surveys to assess percentage of seats being properly used (while gross misuse can be detected this way, most misuse will be overlooked). It is possible that if checkpoints are being employed for other law enforcement purposes, usage of child restraint devices may be sampled. Presumably, as knowledge of the stations increases and publicity continues, the percentage of child safety and booster seats found being used improperly will decrease. Over a period of time, the percentage of improperly used devices found at the inspection stations can be tracked. It will be difficult to evaluate the safety impact of this type of program. The number of infant injuries in crashes would be an appropriate measure, especially if it were feasible to determine the role of improper usage in the injury. A special study of crashes would be required for this, since normal crash reporting practices do not currently provide the desired level of detail.
Associated Needs	Accurate observations are needed to show local data about improper child restraint use before and after the program is implemented and in comparison to statewide averages.
Organizational, Institutional, and Policy Issues	An advocacy group within the community (either public sector or community based) should encourage the implementation of local, readily-available, child safety seat inspection stations.
Issues Affecting Implementation Time	Key elements of the program affecting implementation time will include finding the appropriate sites and training the inspectors.
Costs Involved	Personnel costs might be involved if the inspectors are paid while on duty at the inspection stations. Another possible cost might be surveys of proper child safety seat use. It is assumed that there will be no costs for use of the inspection station locations. PI&E materials may also need to be produced to advertise the locations and educate the public on their role.
Training and Other Personnel Needs	Child safety seat inspectors must be trained and certified. For information on training and certifying inspectors see http://www.nhtsa.dot.gov/CPS/Training/ContactList.cfm.
Legislative Needs	None known at this time.

Strategy 8.1 B2: Conduct High-Profile “Child Restraint Inspection” Events at Multiple Community Locations

This strategy is similar to the first strategy described for this objective. The key difference is that the focus is on a high-profile child restraint inspection event rather than on a single or limited number of inspection locations that are available during specified times only. For this strategy, locations are identified throughout the community on a convenient day (e.g., Saturday). Trained individuals are stationed at those facilities so that people can come to them and have their child restraint use evaluated with minimum wait time. The focus is to educate individuals on proper device use, not on enforcement. Lodi, California, publicizes these events widely, including providing access through their Web page (see http://www.lodi.gov/police/btb/btb%20carseats%202.htm).

EXHIBIT V-8
Strategy Attributes for Conduct of high-profile “Child Restraint Inspection” Events at Multiple Community Locations

Attribute	Description
Target	Parents and others desiring to ensure child safety and booster seats are properly used.
Expected Effectiveness	Effectiveness of this strategy has not been documented. With high-profile events scheduled to check for correct use of child safety and booster seats, the percent of incorrectly used seats in a community would be expected to decrease. Publicity about the inspection events should also encourage the general population of child safety seat users to become more aware of improper use and result in their being more likely to check for proper use on their own. It will be difficult to evaluate the safety impact of this type of program. The number of infant injuries in crashes would be an appropriate measure, especially if it were feasible to determine the role of improper usage in the injury. A special study of crashes would be required for this, since normal crash reporting practices do not currently provide the desired level of detail.
Keys to Success	The primary key to success is to ensure that there are a number of high—visibility inspection stations set up in the community and that each is staffed with a sufficient number of certified technicians so that waiting times for inspections are minimized. All community resources that have an interest in child passenger safety (police, EMS, the medical community, and relevant citizen groups) need to participate and help provide both publicity and the staffing.
Potential Difficulties	None anticipated if there are sufficient sites and inspectors, and information is generated about their availability. There is a need to ensure adequate training of inspectors. Persons receiving such training must be free to use the training when needed. Although police often are the ones trained, they may not be engaged elsewhere when their services are needed. Lodi, California, “Police Partners” (an organization of retired citizens) are receiving the training needed to act as inspectors. They are available for inspections.
Appropriate Measures and Data	Process measures include the number of seats inspected and the number of sites and inspectors involved. The site—hours and/or inspector—hours of service and the number and percent of incorrect usages are identified and corrected. Without actually doing a hands-on inspection of the child safety seat with a child in it, it is difficult to determine if the seat is being properly used. Therefore, it is difficult to use strictly observational surveys to assess percentage of seats being properly used (while gross misuse can be detected this way, most misuse will be missed). It is possible that if checkpoints are being employed for other law enforcement purposes, samples may be taken of proper usage of child restraint devices. Presumably, as knowledge of the stations and publicity continue, the percentage of child safety and booster seats found being used improperly will decrease. If events of this type are done over a period of time, the percentage of improperly used devices found for each event can be tracked.
Associated Needs	Accurate observations are needed to show local data about improper child restraint use before and after the program is implemented and in comparison to statewide averages.
Organizational, Institutional, and Policy Issues	An advocacy group within the community (either public sector or community based) should encourage and be willing to be the primary sponsor of the inspection events.
Issues Affecting Implementation Time	Key elements of the program affecting implementation time will include finding the appropriate sites and training the inspectors.
Costs Involved	Personnel costs might be involved if the inspectors are paid while on duty at the inspection stations. Another possible cost might be surveys of proper child safety seat use. It is assumed that there will be no costs for use of the inspection station locations. Costs associated with PI&E efforts may also be experienced.
Training and Other Personnel Needs	Child safety seat inspectors must be trained and certified. For information on training and certifying inspectors see http://www.nhtsa.dot.gov/CPS/Training/ContactList.cfm.
Legislative Needs	None known at this time.

Strategy 8.1 B3: Train Law Enforcement Personnel to Check for Proper Child Restraint Use in All Motorist Encounters

Unless they have younger children of their own, most police officers have no reason to be familiar with correct use of child restraints. If, on a routine traffic stop or other contact with a motorist, a police officer observes a child in a restraint, most officers will assume the child is being properly protected. All police officers need to be trained and encouraged to look for the common types of misuse of child restraints (see the first strategy in this section) so they can help ensure proper use of these devices.

Like the other strategies in this section, the focus is not on enforcement but rather on education and training. North Carolina and Tennessee train all state troopers in child passenger safety, who are encouraged to check for misuse whenever they have contact with a motorist transporting a child. If improper restraint use is detected, the officer will instruct the adult(s) in charge of the child in proper use, including issuance of written guidelines. A written record of the event should be made so that it is possible to track individuals who continue to use the devices improperly.

Law enforcement agencies may find it difficult to have all their road officers trained and certified as child safety seat technicians. The NHTSA-sanctioned certification course requires attendance for four full days. In a time of increasingly scarce training dollars, many agencies will not be able to make that commitment of staff time for all of their officers. When this is the case, they will need to use other programs that are available for in-service training, so their officers are knowledgeable about the most common errors in child safety seat use. For examples of these programs see http://www.nhtsa.dot.gov/CPS/Training/ContactList.cfm and http://www.csaa.com/global/articledetail/0,8055,1008030000%257C2792,00.html.

In cases where officers are not able to fully correct a problem on-site, they will be able to recognize an unsafe situation and refer the vehicle operator to an inspection station (see Strategy 8.1 B1) where the problem can be fully resolved. An example of the type of brochures agencies provide for the public can be found at http://www.troopers.state.ny.us/Traffic_Safety/Child_Safety_Seats/Help/index.cfm and http://www.saferoads.com/pdf/childsafetyseat.pdf.

Another option is to use Community Service Officers and other law enforcement organizations that assist the police and may have ample opportunity to have contact with motorists. This could be done during parking enforcement, patrols of public parking lots, or in conjunction with special spot checks at local fast food places. The Lee County, Florida, Sheriff's Department has taken active roles in providing such programs in conjunction with fast food retailers (http://www.sheriffleefl.org/).

When officers find child restraints not in use or clearly being used contrary to law, enforcement action should be taken.

EXHIBIT V-9
Strategy Attributes for Training Law Enforcement Personnel to Check for Proper Child Restraint Use in All Motorist Encounters

Attribute	Description
Target	Parents and other adults who are unable or unwilling to ensure that child safety and booster seats are properly used.
Expected Effectiveness	Effectiveness of this strategy has not been documented. Police officers on patrol and making traffic stops will have the opportunity to observe instances of improper child safety seat use. Having officers trained in the most common forms of misuse should aid both the law enforcement agency and community at large in minimizing child restraint misuse.. It will be difficult to evaluate the safety impact of this type of program. The number of infant injuries in crashes would be an appropriate measure, especially if it were feasible to determine the role of improper usage in the injury. A special study of crashes would be required for this, since normal crash reporting practices do not currently provide the desired level of detail.
Keys to Success	The primary key to success is for law enforcement officers to be trained in detection of child safety seat misuse. The most desirable solution would be to have the officers trained and certified as child safety seat technicians. See http://www.nhtsa.dot.gov/CPS/Training/ContactList.cfm for information about certification. For information on training for officers to detect child safety seat misuse, see http://www.theiacp.org/profassist/opkids.htm.
Potential Difficulties	Achieving some minimum acceptable level of training for all relevant officers, primarily because of budget limitations. Trained individuals must be in a position to use their training frequently enough to remain knowledgeable. Officers may not have sufficient time during a contact to complete a thorough inspection.
Appropriate Measures and Data	Process measures include the number of seats inspected and the number and percent of incorrect usages identified and corrected. Without actually doing a hands-on inspection of the child safety seat with a child in it, it is hard to determine if the seat is being properly used. Therefore, it is difficult to use strictly observational surveys to assess percentage of seats being properly used (while gross misuse can be detected this way, most misuse will be overlooked).
Associated Needs	None identified.
Organizational, Institutional, and Policy Issues	The law enforcement agency must be willing to devote resources to ensuring that officers are trained in detecting possible child safety seat misuse. Policy will need to be established to support this strategy and to ensure officer participation. An alternative is to have an assisting organization, such as one consisting of retired citizens as is done in Lodi, California, provide the training or refresher training to the police.
Issues Affecting Implementation Time	Time requirements will hinge upon arranging for trainers and scheduling training of all appropriate personnel.
Costs Involved	Personnel costs might result for trainers and, if they need to receive training during off-duty time, officers.
Training and Other Personnel Needs	Child safety seat inspectors should be trained and certified, and all officers should receive basic training on detecting child safety seat misuse. Officers may also benefit from motivational messages delivered at such times as roll call.
Legislative Needs	None known at this time.

Objective 8.1 C—Provide Access to Materials

Strategy 8.1 C1: Create State-Level Clearing Houses for Materials That Offer Guidance in Implementing Programs to Increase Restraint Use

Since seat belts first began to appear in motor vehicles, there have been campaigns to increase their use. The situation now is that there are so many materials available to assist agencies in implementing campaigns to increase restraint use that those agencies could be overwhelmed in trying to identify what is appropriate for the program they intend or even defining an appropriate, proven, program for their agency.

For this strategy, an agency, either governmental, nongovernmental, or for-profit (such as insurance agencies/companies), but operating throughout a state, will be needed to take on the task of organizing and cataloging materials available to support campaigns to both increase restraint use and ensure proper restraint use. Additionally, this agency could develop guidelines for evaluating those campaigns.

One of the problems with many of the materials designed for increasing restraint system use is that the programs described in those materials have never been thoroughly evaluated. Evaluation is very important for ensuring that a program is accomplishing what it intended. Too often, the only evaluation for a program is anecdotal and the actual effect of the program is never determined. It is important for the state clearinghouse to not only provide materials relating to improving restraint usage but to also have information as to the actual effectiveness of those materials and the program(s) that they describe.

In addition to state sites and the National Highway Traffic Safety Administration (NHTSA), there are few central sources for information and materials on occupant restraint. The American Automobile Association (AAA) has provided one repository for materials at http://www.aaafoundation.org/products/index.cfm. Another resource is Buckle Up America at http://www.buckleupamerica.org/.

EXHIBIT V-10
Strategy Attributes for Creating State-Level Clearing Houses for Materials That Offer Guidance in Implementing Programs to Increase Restraint Use

Attribute	Description
Target	Agencies within the state that desire access to materials to help plan, implement, or upgrade an occupant restraint program.
Expected Effectiveness	The effectiveness of a support program such as this is not possible to measure in terms of effect on crash severity or even restraint usage. Reports of the effectiveness of this type of program have not been identified.
Keys to Success	One key to success for this effort is to ensure that whoever has responsibility for creating the clearinghouse is able to recognize appropriate program evaluations when assessing materials to be included in the clearinghouse. A meaningful method of indexing materials is also necessary. The quality, rather than the quantity, of the material collected should be a primary goal of the clearinghouse. Another important key to success is accessibility of the materials. Every effort should be made to make these materials available quickly and conveniently. Creation of a web site (see the examples cited above), at which persons can search for materials and download them, or arrange for their shipment, is one example of how this may be done. In addition, it is important that persons be available to assist inquirers who have questions during as much of the day as feasible.
Potential Difficulties	Finding an entity within the state willing to devote the resources required. This includes activities to host the clearinghouse, index and assess all materials before they are included therein, continually update and maintain the material, provide shipping and receiving services, and provide assistance to those requiring it.
Appropriate Measures and Data	The attainment of the strategy may be measured both in terms of its existence (i.e., is there one or not and its hours of operation) and its level of use. Measures of use include number of inquiries and pieces of material distributed. The effectiveness of the operation may also be measured by survey of previous and potential users.
Associated Needs	Special services may be needed to operate the clearinghouse. A web site may be used, requiring a web designer and web master. Stock storage and shipping and receiving capabilities may be needed.
Organizational, Institutional, and Policy Issues	All relevant agencies must support the clearinghouse and advocate the use only of materials in it.
Issues Affecting Implementation Time	The time required to implement this will include that necessary to find the facilities, hire and train staff, create a web site, acquire and catalog materials, and prepare public information materials to make potential users aware of the resource. This could take at least 6 months or, more likely, a year.
Costs Involved	Cost elements will include facilities, equipment, operation of a web site, and staff to maintain the operation.
Training and Other Personnel Needs	Staff will need to be trained to assist inquirers. This will require training in the basics of restraint use, an overview of the catalog of materials in terms of their particular type of application, and methods for review and cataloging new materials. A person with a librarian's training or background would be appropriate for one of the staff positions.e.
Legislative Needs	None.

¹For more information, contact Al Goke at agoke@state.mt.us.

²The difference between standard and secondary enforcement is described on page II-1.

³http://www.nhtsa.dot.gov/people/injury/airbags/buckleplan/BUA_WEBSITE/Archive-04/Cases/NorthCarolina.html.

⁴Safety Belt and Helmet Use in 2002 (Glassbrenner, 2002).

⁵Putting Children First, National Transportation Safety Board, Washington, D.C. NTSB/SR-00/02, 2000

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Boyle, John, and Kevin Sharp. 1996 Motor Vehicle Occupant Safety Survey, Volume 3: Seat Belt Report. Final Report DOT HS 808 632. Washington, D.C.: Research and Development, National Highway Traffic Safety Administration, 1997c.

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Campbell, B. J. Increasing Safety Belt Use Through an Incentive Program. Chapel Hill, North Carolina: University of North Carolina, Highway Safety Research Center, 1982.

Campbell, B. J. The Relationship of Seat Belt Law Enforcement to Level of Belt Use. Chapel Hill, North Carolina: University of North Carolina, Highway Safety Research Center, 1987.

Campbell, B. J., and Frances A. Campbell. Seat Belt Law Experience in Four Foreign Countries Compared to the United States. Chapel Hill, North Carolina: University of North Carolina, Highway Safety Research Center, 1986.

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