Accident Analysis and Prevention 43 (2011) 889–897

Contents lists available at ScienceDirect

Accident Analysis and Prevention

journal homepage: www.elsevier.com/locate/aap

Attitudes and behavior of Chinese drivers regarding seatbelt use

Yueng-Hsiang Huang a,∗, Wei Zhang b, Lauren Murphy c, Guangyuan Shi b, Yanjie Lin b a Liberty Mutual Research Institute for , 71 Frankland , Hopkinton, MA 01748, USA b Department of Industrial Engineering, Tsinghua University, Beijing, China c Department of Psychology, Portland State University, Portland, OR, USA article info abstract

Article history: In the current study, research was conducted in five cities in China to examine seatbelt use and to explore Received 18 May 2010 Chinese drivers’ attitudes toward using seatbelts. Multiple data collection methods consisted of 35 initial Received in revised form 20 October 2010 semi-structured interviews to create questions for an in-person survey and 500 driver observations that Accepted 8 November 2010 included administering the in-person survey. Questions explored were why Chinese drivers use or do not use seatbelts and what they think would be the best interventions to increase the rate of seatbelt use in Keywords: Chinese drivers. The relationships between various personal characteristics and seatbelt use rates were Chinese drivers investigated. Also examined were the relationships between seatbelt use (both objective observation Seatbelt use and subjective self-reported use) and self-reported car crashes and traffic violations. This study provides insight into the attitudes of Chinese drivers on seatbelt use and potential interventions. © 2010 Elsevier Ltd. All rights reserved.

1. Introduction increase by 92% between 2000 and 2020 (Kopitis and Cropper, 2005). These numbers are alarming, and are made more so when 1.1. Why research seatbelt use in China? it is stated that traffic fatalities are the leading cause of death in China for people up to 45 years of age (Hu et al., 2008). Compared China is not only the largest developing country, but it is clas- to the , the largest developed country, during approx- sified as the largest country overall by population with over 1.3 imately the same time period, the fatalities for China per vehicle billion people (The World Bank, 2010). Along with the increase in (China: US = 17.6:1) and per driver (China: US = 6.7:1) were much population and development in China has come a growth in the higher (AUSTST, 2002; CRTAS, 2002). As seen by the drastic differ- demand for motor vehicles. The nation’s sales of passenger cars, ence between the US and China, and given the fact that over 90% and have increased dramatically from over 5 million of traffic fatalities occur in low-income and middle-income coun- in 2004, to over 8 million in 2007, and to 13.6 million in 2009 tries (World Organization, 2009), it is obvious that more (CAAM, 2010), making China the world’s largest market for motor attention regarding road safety is vital for those countries in the vehicles. During the 1990s, production tripled in most need. China (Zhou et al., 2003), and in 2009, China became the world’s There have been many research studies showing that the largest manufacturer, as well as consumer, of automobiles, achiev- number of injuries from vehicle accidents has been significantly ing 23% of the worldwide production of motor vehicles (ACEA, decreased by the use of seatbelts, with seatbelts minimizing the 2010). extent of those injuries that do occur (Bendak, 2005; Cooper, 1994; With so many vehicles on the , the traffic fatality num- Evans, 1996; Koushki et al., 2002; Wang and Jiang, 2003). By ber in China climbed to 109,381 people in 2003, with that being restraining people in their seats during vehicle accidents, seatbelts the highest number in any country (CRTAS, 2003), accounting for prevent the occupants from being ejected from the vehicle or from roughly 20% of the total traffic fatalities in the entire world that hitting objects that are close by, thereby reducing the severity of year. The number of traffic fatalities in China increased by 95% injuries suffered. According to the Traffic Safety Adminis- between 1985 and 2005, with 3.9 deaths per 100,000 people in tration (NHTSA, June 2009), use of seatbelts in passenger cars saved 1985 to 7.6 deaths per 100,000 people in 2005 (Hu et al., 2008), an estimated 13,250 lives in the US in 2008 and over 75,000 lives and it is predicted that deaths as a result of traffic accidents will between 2004 and 2008. The United States had a national seat- belt use rate in 2008 of 83%, ranging from 66.8% in Massachusetts to 97.2% in Michigan (NHTSA, April 2009). The National Safety Council reports it is estimated that in 2007 more than 1600 lives ∗ Corresponding author. Tel.: +1 508 497 0208; fax: +1 508 435 0482. could have been saved and 22,000 injuries prevented if seatbelt use E-mail address: [email protected] (Y.-H. Huang). were at least 90% in every state in the US (National Safety Council,

0001-4575/$ – see front matter © 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.aap.2010.11.009 890 Y.-H. Huang et al. / Accident Analysis and Prevention 43 (2011) 889–897

2010). The rates in other developed countries are 90% or more (Eby 1.3. The relationship between certain personal characteristics et al., 2000, 2002; Eby and Vivoda, 2003; European Transport Safety and seatbelt use Council, 1996; Filde et al., 2004; Transport , 2000; Vivoda et al., 2004; Wells et al., 2002). Many studies have shown that certain personal characteristics Recently, several studies started exploring seatbelt use in China (e.g., gender, socioeconomic status) were correlated with seatbelt and showed that the seatbelt use rate varied widely between 7% use rate (e.g., Bendak, 2005; Wells et al., 2002). Li et al. (2006) and 65% (Fleiter et al., 2009; Passmore and Ozanne-Smith, 2006; compared two types of personal characteristics in their study con- Routley et al., 2008; Stevenson et al., 2007; Zhang et al., 2006). For ducted in China – drivers of different car types (taxi/passenger example, one observational study conducted in Beijing, in which car/other type) and male versus female drivers – to see whether approximately 2300 drivers were observed, indicated the average there were differences in the use and non-use of seatbelts. The use rate was 63.6% (Zhang et al., 2006). Routley et al. (2008) found results of their study showed that people who drove passenger the rate of wearing seatbelts was 49.9% in Nanjing and 47.4% in cars and female drivers had higher rates of proper use of seat- Zhoushan for drivers, 9.1% in Nanjing and 1.0% in Zhoushan for front belts in both Guangzhou and Nanning cities. The current study will seat passengers, and 0.5% in Nanjing and 0.2% in Zhoushan for rear continue exploring possible correlations between personal charac- passengers. Another study from Routley et al. (2009) also found teristics and the rate of seatbelt use for Chinese drivers. that 31.7% of taxi drivers (results from roadside observation) and The personal characteristics in the current study selected as 20.4% (in-taxi observation) in Nanjing use seatbelts. A smaller study important factors, which might relate to seatbelt use in China, were observing 235 taxi drivers in Beijing in 2004 revealed that only chosen from prior studies conducted in China (e.g., Li et al., 2006) 7.7% were correctly wearing a belt (Passmore and Ozanne-Smith, and in Western societies (e.g., Bendak, 2005; Wells et al., 2002), and 2006). This wide variation makes it difficult to have a relatively from the results suggested from in-depth interviews in the current clear understanding of the nationwide seatbelt use situation. One project. The results of the study should provide useful information limitation of these prior studies is that all the cities examined (Bei- on who should be in the targeted group when conducting seatbelt jing, Nanjing, Guangzhou, Nanning, and Zhoushan) are very large interventions in China. cities. It is obvious that more research is needed to explore the issue Purpose 2. To investigate the relationships between various per- of safety belt use in China (Zhang et al., 2006). sonal characteristics and seatbelt use rate. A few studies have provided information on the design of interventions for developing and low-income countries for improv- 1.4. Relationships between seatbelt use and self-reported car ing road safety (e.g., Forjuoh, 2003; Forjuoh and Li, 1996). One crashes and traffic violations study in particular (i.e., Stevenson et al., 2007) involved a seat- belt intervention project in China which included three sections: Research in Western societies has also shown that non-users of health promotion (e.g., running television ads), training program seatbelts have characteristics that put them at a higher crash risk. (e.g., conducting train-the-trainer programs), and law enforcement For example, non-users are more likely to drive after drinking, and improvement (e.g., better execution of the laws by ). After they have been found to be more likely than seatbelt users to tail- spending 3 million RMB (approximately 400K US dollars) for the gate, run red lights, and drive at illegally high speeds (Evans, 1987; project, the authors reported that, although there was a significant Lund, 1986; Preusser et al., 1991; Reinfurt et al., 1996; Wells et al., increase in the prevalence of seatbelt use in the intervention city 2002). This results in a situation in which those who most need the (Guangzhou) compared to the control city (Nanning), the preva- protection of the belts are less likely to use them. The current study lence of seatbelt use in the intervention city remains low (62%) examines the relationship between seatbelt users/non-users and when compared to other highly motorized countries (e.g., 83% in their self-reported car crash and traffic violation information to see the US and 95% in ). It was reported by the project inves- whether this situation occurs in China as well. tigators that the level of change was not as originally expected. Purpose 3. To investigate the relationships between seatbelt use (both objective observation and subjective self-reported use) and 1.2. The attitudes of Chinese drivers regarding seatbelt use self-reported car crashes and traffic violations.

According to the Theory of Planned Behavior (Ajzen, 1988, 2. Methods 1991), attitudes influence behavior. If attitudes toward specific behaviors are clearer, there may be a better chance for affecting This study employed multiple data collection methods and con- change in the behavior. Although prior intervention studies (e.g., ducted research in multiple regions in China. Data were collected Stevenson et al., 2007) have shown some success in improving the in five cities of different sizes (Beijing – capital, 16.3 Million (M) in seatbelt use in China, perhaps it could be improved upon through population; Tianjin, 11.2 M; Yantai, 0.88 M; Changzhi, 0.61 M; and a more in-depth examination of Chinese drivers’ attitudes toward Pingyi, 0.34 M). The data collection methods included (1) in-depth seatbelt use. Stevenson et al. (2007) made a start, from their focus semi-structured interviews to initially explore Chinese drivers’ atti- group results, at illustrating some reasons for Chinese seatbelt tudes toward seatbelt use (using the results to develop survey non-use, such as “forgetting,” “uncomfortable,” “annoying,” “low questions), (2) direct observation of drivers for seatbelt use when speed,” and “traveling short distances.” Quantitative data needs to entering gas stations, and (3) administration of survey to drivers be gathered and analyzed to examine why Chinese drivers wear being observed at gas stations to collect quantitative data in each or do not wear seatbelts in order to determine the best meth- of these five cities. ods/interventions for improving seatbelt use for Chinese drivers. The first purpose of this study is: 2.1. A qualitative approach to initially explore Chinese drivers’ attitudes toward seatbelt use Purpose 1. To examine Chinese drivers’ attitudes toward seatbelt use, using both qualitative and quantitative methods, by exploring Thirty-five in-depth semi-structured interviews with subject the reasons why Chinese drivers use or don’t use seatbelts and what matter experts (i.e., professional drivers, experienced drivers, they think would be the best interventions to increase the rate of police officers) were conducted to examine Chinese drivers’ atti- seatbelt use in Chinese drivers. tudes toward seatbelt use by exploring the reasons why Chinese Y.-H. Huang et al. / Accident Analysis and Prevention 43 (2011) 889–897 891 drivers use or do not use seatbelts and what they think would be observed the next car to arrive. This method has been previously the best interventions to improve seatbelt use for Chinese drivers. utilized in Wells et al. (2002). Surveys were conducted with drivers Recruitment of participants included drivers working or studying until 50 drivers participated from each gas station. Response rates at universities and personal contacts. Participants were licensed ranged from 79% to 83%. The total number of survey participants drivers with at least 12 months of active experience. An was 500 (50 participants for each of the 2 gas stations per city, with incentive was provided (40RMB = 5 US dollars) for participation. Fif- a total of 100 participants for each of the five cities). teen interviews were conducted in Beijing with an additional five interviews in each of the four other cities. Informed consent was 3. Results obtained. Interviews were conducted at a location convenient for participants. The interviews lasted approximately 30 min. Facilita- 3.1. In-depth semi-structured interviews with subject matter tors asked four open-ended questions to collect data regarding the experts project purposes. The questions focused on their opinions about: driving situations in which they would/would not be likely to wear Thirty-five in-depth semi-structured interviews were con- a seatbelt, why Chinese drivers wear seatbelts, why Chinese drivers ducted with subject matter experts in five cities in China to explore do not wear seatbelts, and what would be the best interventions to Chinese drivers’ attitudes toward and the perceived important fac- increase seatbelt use. Notes were taken during the interviews and tors which may relate to seatbelt use. The interview results were transcribed. Comments in reaction to the open-ended questions used to develop a questionnaire (see Appendix A). were content analyzed by three members of the project team. Cat- egories were first created by one project member and two other 3.2. Participants involved in direct observation and survey in gas members sorted participants’ responses into each category inde- stations pendently. Any discrepancies were discussed among the project team until consensus was reached. The interview results were used 3.2.1. Observed seatbelt use rates in multiple cities to create a survey questionnaire. The average observed seatbelt use rate when drivers entered the gas stations was 36.2% for these 500 drivers. The use rates for 2.2. Direct observation and survey of drivers in gas stations the five study cities (from large to small in population) were 47% in Beijing, 23% in Tianjin, 41% in Yantai, 47% in Changzhi, and 23% in 2.2.1. Survey measures Pingyi. The survey included three parts: (1) attitudes toward seatbelt use, self-report of seatbelt use, (2) personal characteristics and 3.2.2. Survey results demographic variables, including age, gender, education, years of 3.2.2.1. Demographic information. Among the participants, 84% driving, annual driving distance, size of residence city, driver type (n = 420) were male drivers, the average age was 36.81 years, the (professional/non-professional), and (3) self-report of crashes and average driving distance was 32,613 KM per year, and the aver- of traffic violations in the prior year. The primary part of the sur- age amount of driving experience was 9.86 years. Regarding the vey included questions exploring drivers’ attitudes toward seatbelt highest level of education attained, the largest percentage of par- use, whether or not they generally wear a seatbelt, opinions on why ticipants graduated from high school (43.4%). Professional drivers Chinese drivers use or do not use seatbelts, and potential interven- comprised 22.8% (n = 114) of the drivers in the sample. Forty- tion suggestions for increasing the rate of seatbelt use in China (see Appendix A). Ten cognitive interviews were conducted to clarify survey items. The final draft of the survey questions was pilot- Table 1 tested with ten drivers recruited at a gas station. The pilot test Descriptive information of survey participants. demonstrated the feasibility of recruiting participants and conduct- Gender Male (84.0%, n = 420) ing surveys at gas stations. Female (16.0%, n = 80) We believe that the survey items used in this study sampled Education level No education (0.4%, n =2) the content of what we wanted to measure. Content validity refers Elementary (3.0%, n = 15) to the degree to which a measure covers the range of meanings Middle school (24.6%, n = 123) included within the concept (Babbie, 1995). Content validity is High school (43.4%, n = 217) College (26.6%, n = 133) assessed by subject matter experts (SMEs) in the area the test cov- Graduate school (2%, n = 10) ers. The SMEs render an opinion regarding the degree of content Yes (22.8%, n = 114) validity manifested in the test (Muchinsky, 1997). Our survey items Professional drivers No (77.2%, n = 386) were developed based on the results of interviews with SMEs, and the initial survey questions were reviewed, revised, and pilot tested Number of traffic violations 0 Tickets (49.4%, n = 247) (tickets) 1 Ticket (26.2%, n = 130) by actual Chinese drivers. We assume this questionnaire achieves 2 Tickets (12.2%, n = 61) content validity. 3 Tickets (6.6%, n = 34) 4 Tickets (3.0%, n = 15) 2.2.2. Procedure 5 Tickets (1.2%, n =6) Data were collected at two gas stations in each of the five cities. 6 Tickets (1.4%, n =7) Project staff observed the first arriving car as it entered the station Type of traffic violations Speeding (n = 148) and noted seatbelt use by the driver. The staff then approached the (tickets) (n = 108) Run red light (n = 80) driver at the pump to recruit him/her for the survey. If the driver Make a turn illegally (n = 61) declined, the staff went back to the entrance to observe the next car. Change illegally (n = 57) Participants agreeing to the survey were asked to park their car in a Drink and drive (n = 21) nearby parking space. A verbal consent statement was given to the (n = 11) participants. It took approximately 10 min to complete the survey. Others (n =2) An incentive was provided to all the survey participants (40RMB = 5 Have car incidents/major crash in Yes (9.0%, n = 41) US dollars for participation). Once the survey process was com- the prior 12 months of driving No (91%, n = 459) pleted, the project staff returned to the gas station entrance and Note: N = 500. 892 Y.-H. Huang et al. / Accident Analysis and Prevention 43 (2011) 889–897

Table 2 Intercorrelations among study variables.

Variables 2345678910112

1. Age .03 −.05 .62** .03 .09* −.03 −.01 .08 .05 −08 −.06 2. Gender – −.16** .23** .26** −.06 .22** −.08 −.06 −.09* −.03 .02 3. Education – −.09 −18** .14** −.21** .06 .16** .15** .03 −.14** 4. Years of driving – .24** .07 .24** −.10* .03 −.08 −.08 −.03 5. Annual driving distance – −.03 .36** .08 .04 −.08 −.02 −.03 6. Size of residence cities – −.00 −.01 .13** .07 .07 −.01 7. Professional driver – −.04 .14** −.06 −.09* −.04 8. Attitude toward seatbelt use – .31** .25** −.09* −.22** 9. Drivers’ self-reported seatbelt use – .62** −.10* −.30** 10. Observed seatbelt use – −.06 −.14** 11. Self-reported crash prior year – .24** 12. Self-reported traffic violations –

Note: Male was coded as 1 and female was coded as 0. Professional driver was coded as 1, and not a professional driver was coded as 0. Observed wearing seatbelt was coded as 1 and not using seatbelt was coded as 0. Report having crash in the prior year was coded as 1 and no crash was coded as 0. For all the other variables, the higher numbers represent higher levels of the factors (i.e., older, higher level of education, more years of driving, greater annual driving distance, and live in larger cities). * Correlation is significant at alpha < 0.05, two-tailed. ** Correlation is significant at alpha < 0.01, two-tailed.

five people (9%) reported having a major car crash and 50.6% passengers, and 1.13% (SD = 7.20) for back seat passengers. Three of drivers reported having at least one traffic violation (ticket) questions asked the participants to estimate their own percentages in the prior 12 months. Speeding, illegally parking, and run- of time wearing seatbelts. The results showed that, in general, as the ning red lights were the three most reported traffic violations driver of the car, they estimated that they wore a seatbelt 63.05% among participants. Further demographic information is reported (SD = 37.40) of the time, 14.83% of the time as the front seat pas- in Table 1. Correlations between study variables are provided in senger (SD = 27.81), and 0.82% of the time as a back seat passenger Table 2. (SD = 6.60). One question asked, “If there are kids in your car, where do they usually sit?” Fifty-one participants (10.2%) reported “front 3.2.2.2. Estimation of seatbelt use. Several questions asked partici- seat,” 340 (68.0%) reported “back seat,” and 109 (21.8%) reported pants to estimate the seatbelt use rates for various situations. Three “no consistency.” Another item asked the participants, “If there are questions asked participants to estimate the seatbelt use rates for kids in your car, do they wear seatbelts in general?” Participants general drivers, front seat passengers, and back seat passengers in who reported “no” comprised 76.8% (n = 383) of the sample. Among China. The average estimations of seatbelt use rates were 53.97% the 23.2% (n = 116) of participants who said “yes,” the average was (SD = 29.82) for general drivers, 12.10% (SD = 20.43) for front seat 65.99% (SD = 32.22) of the time.

Table 3 Participants’ evaluation of various driving situations and the likelihood that they will use a seatbelt, using “>”, “<” or “=” to compare the likelihood in each situation. A comparison of how much more (>), less (<) or equal to (=) they are to use a seatbelt under one condition (Situation A) than the other (Situation B). “>” indicates that the seatbelt use rate of the prior factor is higher than the one after, and “<” indicates that the seatbelt use rate of the prior factor is less than the one after.

Participants’ likelihood of using a seatbelt in Situation 1 compared to Situation 2

Response 1 Response 2 Response 3 2 2 2 Comparison between Situation A to Situation B A > B A = B A < B Responses 1 Responses 2 Responses 3 versus 2 versus 3 versus 1

1. On an expressway/highway (A) versus on urban 435 (87.0%) 41 (8.2%) 24 (4.8%) 326.13* 4.45* 368.02* roads (B) 2. On countryside roads (A) versus on urban roads (B) 70 (14.0%) 191 (38.2%) 232 (46.4%) 56.10* 3.97* 86.90* 3. On a winding mountain road (A) versus on a 183 (36.6%) 263 (52.6%) 54 (10.8%) 14.35* 137.80* 70.22* straight, flat road (B) 4. In bad weather (A) versus in good weather (B) 196 (39.2%) 264 (52.8%) 40 (8.0%) 10.05* 165.05* 103.12* 5. In very hot weather (A) versus when the weather 17 (3.4%) 286 (57.2%) 196 (39.2%) 238.82* 16.81* 150.43* temperature is nice (B) 6. In very cold weather (A) versus when the weather 32 (6.4%) 420 (84.0%) 48 (9.6%) 333.06* 295.69* 3.20 temperature is nice (B) 7. In day time (A) versus at night (B) 63 (12.6%) 376 (75.2%) 61 (12.2%) 223.16* 227.06* 0.03 8. Driving to/from work during a weekday (A) versus 24 (4.8%) 466 (93.2%) 10 (2.0%) 398.70* 436.84* 5.76* driving for pleasure during the weekend (B) 9. When the is good (A) versus when 41(8.2%) 399 (79.8%) 60 (12.0%) 291.28* 250.37* 3.57 the road surface is bad (B) 10. When you drive alone (A) versus when there are 22 (4.4%) 452 (90.4%) 26 (5.2%) 390.08* 379.66* 0.33 other people in the car (B) 11. When you see police officers are around (A) 331 (66.2%) 168 (33.6%) 1 (0.2%) 53.24* 165.02* 328.01* versus when you see no police are around (B) 12. When you are driving for a long-distance travel 334 (66.8%) 161(32.2%) 5 (1.0%) 60.46* 146.60* 319.30* (A) versus when you are driving for a short distance (B) 13. When you know many other drivers in China are 118 (23.6%) 382 (76.4%) 0 (0%) 139.39* 382.00* 118.00* wearing seatbelts (A) versus when you know few other drivers in china are wearing seatbelts (B)

Bold values indicate the most chosen response for each question. * p < .05. Y.-H. Huang et al. / Accident Analysis and Prevention 43 (2011) 889–897 893

Table 4 Chinese drivers’ attitudes toward use.

Participants’ responses to the request to choose the Safer 30.4% (n = 456) three most important reasons why Chinese drivers Avoid penalty 21.1% (n = 316) wear seatbelts (a total of 1500 possible counts) Already have the habit 10.3% (n = 154) My family asks me to 5.9% (n = 89) My company asks me to 0.6% (n =9) Other reasons (e.g., obeying the rule, belt ) 1% (n = 15) No responses 30.7% (n = 461) Participants responses to the request to choose the Too much trouble 19.0% (n = 285) three most important reasons why Chinese drivers Uncomfortable 15.4% (n = 231) do not wear seatbelts (a total of 1500 possible Only traveling short distances 10.9% (n = 163) counts) No needed at low speeds 10.3% (n = 155) Do not have the safety consciousness 8.8% (n = 132) Forget 4.9% (n = 74) Trust their own driving skill 1.6% (n = 24) Not used to 1.4% (n = 22) When not moving in a traffic jam 0.8% (n = 12) Other reasons (e.g., belt too dirty, following most people, not important) 1.4% (n = 22) No responses 25.5% (n = 382) Participants’ responses to the request to choose Health promotion (for example, running television ads) 22.0% (n = 330) the three best interventions to increase seatbelt Law enforcement improvement (for example, more executing/enforcement of the laws by police) 16.8% (n = 252) use rate in China Increase the penalty for not wearing a seatbelt 13.4% (n = 201) Improve seatbelt warning signals inside the car (will warn people if not wearing seatbelt) 8.4% (n = 126) Improve the design of seatbelts, make them more comfortable 5.7% (n = 86) Training (for example, strengthen the importance of using seatbelts in drivers’ training school) 4.9% (n = 73) Add more safety signs on the side of the road to remind people about wearing seatbelts 3.3% (n = 50) Promote/ask family and friends to encourage drivers to use seatbelts for safety 1.9% (n = 29) Others (e.g., belt warning) 0.5% (n =8) No responses 23.0% (n = 345)

Note: N = 500.

3.2.2.3. Factors affecting seatbelt use rates. One set of questions on top three chosen best interventions to increase the rate of seatbelt the survey asked participants to evaluate various driving situations use in China were: “Health promotion (for example, running televi- and to compare the likelihood in each situation that they would use sion ads)” 22.0% (n = 330), “Law enforcement improvement” 16.8% a seatbelt. The purpose of these questions was to explore whether (n = 252), and “Increase the penalty for not wearing a seatbelt” 13.4% there are factors affecting people’s use of seatbelts in China. Results (n = 201). are shown in Table 3. The inferential test of Chi-square statistics based on the differences between observed and expected frequen- 3.2.2.5. The relationship between various personal characteristics and cies was applied to each comparison of different responses given by seatbelt use rate. For Purpose 2, data from both the direct obser- participants. Looking at the most chosen response for each driving vation (objective data) and the survey of drivers in gas stations situation reveals that, in most of the situations, they saw no differ- (self-reported data) were used to investigate the relationships ences (i.e., choosing “=”) between the proposed factors as far as their between the seatbelt use rate and drivers’ personal characteris- likelihood of using a seatbelt. These “no difference” responses were tics. First, multiple regression was used to analyze the impact all significantly chosen over the more (>) or less (<) responses. How- of personal characteristics on drivers’ estimated percentage of ever, there were some significant differences in choices for a few time wearing seatbelts. Results from Table 5 show that hav- specific situations. It showed that participants reported they would ing a higher education level (beta = .16, p < .01), living in larger be more likely to wear seatbelts “on an expressway/highway” than cities (beta = .09, p < .05), being a professional driver (beta = .21, “on urban roads” and more likely “on urban roads” than “on coun- p < .01), and having a better attitude toward the importance of tryside roads.” Participants reported they would be more likely to wearing seatbelts (beta = .31, p < .01) were significant predictors of wear seatbelts “when they see police officers are around” compared to “no police are around” and more likely “when they are driving for a long-distance travel” than “driving for a short distance.” Table 5 Regression effects on drivers’ self-reported percentage of time wearing seatbelts.

Independent variable Beta p-value 3.2.2.4. Chinese drivers’ attitudes toward seatbelt use. One question asked participants, “Do you agree that it is important in general to Age .11 .05 Gender −.04 .32 wear a seatbelt when you drive a car?” on a 5-point Likert scale Education level .16** .00** from 1 “Disagree” to 5 “Agree.” The average was 4.7 (SD = .69). Four Years of driving −.03 .57 hundred (80%) of the participants chose “agree.” Annual driving distance (KM) −.02 .74 Results in terms of Purpose 1, regarding Chinese drivers’ atti- Residence city size .09* .03* ** ** tudes toward seatbelt use (why Chinese drivers use or do not Professional driver or not .21 .00 Attitude toward seatbelt use .31** .00** use seatbelts and what they think would be the best interven- 2 tions to improve seatbelt use for Chinese drivers), are shown in R .17 Table 4. The top three reasons reported for why Chinese drivers Note: Male was coded as 1 and female was coded as 0. Professional driver was coded wear seatbelts were: “Safer” 30.4% (n = 456),” “Avoid penalty” 21.1% as 1, and not a professional driver was coded as 0. For all the other variables, the (n = 316), and “Already have the habit” 10.3% (n = 154). The top three higher numbers represent higher levels of the factors (i.e., older, higher level of education, more years of driving, greater annual driving distance, and live in larger reasons reported for why Chinese drivers do not wear seatbelts cities). were: “Too much trouble” 19.0% (n = 285), “Uncomfortable” 15.4% * p < .05. (n = 231), and “Only traveling short distances” 10.9% (n = 163). The ** p < .01. 894 Y.-H. Huang et al. / Accident Analysis and Prevention 43 (2011) 889–897

Table 6 Regression effects on observed seatbelt use of participants.

Independent variable B SE Wald Exp(B) 95% C.I. for EXP(B)

Lower Upper

Age .034* .016 4.68 1.034 1.00 1.06 Gender −.113 .278 .16 .894 .52 1.54 Education level .306* .306 6.25 1.358 1.07 1.73 Years of driving −.037 .122 3.8 .963 .93 1.00 Annual driving distance (KM) .000 .000 1.03 1.000 1.00 1.00 Residence city size .076 .071 1.14 1.079 .94 1.24 Professional driver or not .094 .270 .12 1.098 .65 1.87 Attitude toward seatbelt use 1.31** .275 22.54 3.698 2.16 6.34 Constant −.897 1.555 33.31 .000

Note: Male was coded as 1 and female was coded as 0. Professional driver was coded as 1, and not a professional driver was coded as 0. For all the other variables, the higher numbers represent higher levels of the factors (i.e., older, higher level of education, more years of driving, greater annual driving distance, and live in larger cities). * p < .05. ** p < .01. self-reported seatbelt use. There were no differences concerning of our study on seatbelt use rates were consistent with and similar participants’ age, gender, years of driving, and annual driving dis- to prior studies. tance. Second, logistic regression was used to analyze the impact According to the participants, only 68% of children sit in the back of personal characteristics on observed seatbelt use. Results from seats (recommended in Western societies) and 76.8% of children do Table 6 show that being an older driver (z = 4.68, p < .05), having a not wear seatbelts. Since the use of seatbelts significantly decreases higher education level (z = 6.25, p < .01), and having a better atti- vehicle accident injuries, and with the results of the current study tude toward the importance of wearing seatbelts (z = 22.54, p < .00) showing the high crash rates and traffic violations in China, it is very were significant predictors of observed seatbelt use. There were no important for future studies to identify ways to improve the use of differences concerning participants’ gender, years of driving, res- seatbelts for both drivers and passengers in China and, potentially, idence city size, annual driving distance, and professional driver for other developing countries with low levels of seatbelt use. or not. Our results also showed that, for Chinese drivers, the use of seat- belts may vary in different situations. For example, people reported 3.2.2.6. Seatbelt use and self-reported car crashes and traffic viola- being more likely to wear seatbelts when driving on highways than tions. For Purpose 3, data were used to investigate the relationships urban roads or countryside roads and when driving for a long dis- between seatbelt use (both objective observation and subjective tance than for a short distance. These indicators suggest that drivers self-reported use) and self-reported car crashes and traffic viola- in China not only have low levels of seatbelt use, but that those who tions. Self-report of the percentage of time wearing seatbelts was do wear seatbelts may not make a regular habit of doing so and may negatively correlated to car crashes (r = −.10, p < .05) and number use personal judgments to determine when they need to use a seat- of traffic violations (r = −.30, p < .01). Observed seatbelt use was not belt. This shows that not only is there a need to increase the seatbelt significantly correlated to self-reported car crashes, but was sig- use rate for drivers, but efforts are also needed to increase the con- nificantly correlated to the number of traffic violations (r = −.14, sistency and the habit for Chinese drivers to wear seatbelts across p < .01). all driving situations. The results of the study provide some insights into Chinese 4. Discussion drivers’ attitudes toward seatbelt use and suggested best inter- ventions for increasing their use. Drivers reported the number The current study employed multiple data collection methods one reason why they wear seatbelts was because it is “safer,” and conducted research in multiple cities of various sizes to exam- although this reason was chosen by less than one third of the drivers ine seatbelt use in China and to explore Chinese drivers’ attitudes (30.4%). This indicates that efforts are needed in increasing drivers’ toward seatbelt use. The potential factors which may impact seat- understanding of how important it is to wear seatbelts. This was belt use (i.e., various driving conditions, personal characteristics) tied/linked to the number one best intervention chosen by partici- and safety outcomes that may be related to seatbelt use (i.e., car pants, which was “health promotion (e.g., running television ads).” crashes, traffic violations) were also explored. General public education on the importance of wearing seatbelts In general, from both observation data and self-reported data, may be the most pressing need for improving seatbelt use in China. drivers’ seatbelt use rate is very low in China and much lower com- This may have an impact not only for drivers, but also for all the pared to developed countries. Our results showed that the average passengers, including children. Increasing awareness and improv- observed seatbelt use rate when drivers entered the gas stations ing people’s attitudes and perceptions toward seatbelt use in China was 36.2% for these 500 drivers. The use rates for the five study is critical. cities (from large to small in population) were 47% in Beijing, 23% According to the driver’s manual published by the Ministry of in Tianjin, 41% in Yantai, 47% in Changzhi, and 23% in Pingyi. These Public Security of the People’s Republic of China (2010), drivers will numbers were consistently within the range, 7–65%, illustrated by not pass the licensing test if they are not correctly wearing seatbelts prior studies (e.g., Fleiter et al., 2009). From the self-reported data during the test. By law, drivers and passengers of motor vehi- of our study, participants estimated the average seatbelt use rates cles are required to properly wear seatbelts (The Central People’s were 53.97% for general drivers, 12.10% for front seat passengers, Government of the People’s Republic of China, 2010). However, the and 1.13% for back seat passengers. The pattern is consistent with results of the current study illustrated the reality of low seatbelt the results from the observation study conducted by Routley et al. use rates in China. (2008) (49.9% in Nanjing and 47.4% in Zhoushan for drivers, 9.1% in Chinese drivers mainly receive information about the safety Nanjing and 1.0% in Zhoushan for front seat passengers, and 0.5% in benefits of seatbelts and general traffic safety when they attend Nanjing and 0.2% in Zhoushan for back seat passengers). The results driver education and license testing. Huang et al. (2006), during Y.-H. Huang et al. / Accident Analysis and Prevention 43 (2011) 889–897 895 focus groups with dual-country drivers, found that the train- people in China. Social learning theory, which states that people ing/licensing process in China seems to be more strict compared learn from each other through observation, imitation, and modeling to the US. People must attend more training classes before apply- (Bandura, 1977), can be used by showing people, through such tools ing for driving licenses; however, people may not have enough real as public service announcements, that wearing seatbelts is essen- road experience in China when they pass the driving tests. This may tial. It would be important to target those individuals who have a be due to the situation that most people learn how to drive at driv- lower seatbelt use rate (i.e., younger drivers and drivers with lower ing school within isolated training areas and take the driving tests levels of education) by using actors in the ads who are similar to in the same school. Some schools focus mainly on teaching students the target audience to make more of an impact on those who need how to pass the test instead of how to drive safely on the real road. it. Also, it is vital that professional drivers (e.g., taxi drivers) always A study by Zhang et al. (2006) explored driver differences and properly wear their seatbelts because they serve as examples to similarities between China and the US and suggested that Chinese their passengers. As it stands now, many taxi drivers do not obey drivers concentrate more on driving skills and capabilities, whereas China’s Road Traffic Safety Law implemented in 2004 that requires US drivers concentrate more on practical safe driving measures. drivers and front seat passengers to wear seatbelts (Peden et al., Their study results also showed that in China, the safety belt use 2004). Passmore and Ozanne-Smith (2006) found that only 7.7% of ratio was about 64% in Beijing, use of running lights was nearly taxi driver in Beijing were correctly wearing their seatbelts, with zero during rainy and snowy weather, use of headlights after sunset a large percentage (92.3%) either not wearing a seatbelt or wear- was substantially delayed, and only about 40% of drivers used turn ing the seatbelt non-functionally (i.e., draping the seatbelt over the signals to indicate their intention to change . These unsafe without fastening the belt latch). In a recent study, taxi behaviors may show that Chinese drivers do not have accurate safe drivers in Nanjing were observed from the roadside and from inside driving knowledge. the taxis, and they were found to wear their seatbelts only 43.8% The second most chosen reason why Chinese drivers wear seat- and 36.2% of the time, respectively (Routley et al., 2009). belts, to “avoid penalty,” is consistent with the suggestions on the Similar to the situations in Western societies (e.g., Lund, 1986), reported best interventions of “law enforcement improvement” seatbelt non-users in China have a higher risk in terms of traf- and “increase the penalty for not wearing a seatbelt.” It suggests fic violations and car crashes. This results in a situation in which that improving law enforcement of seatbelt use and increasing those who most need the protection of the belts are least likely to the penalty for not complying with the law might be appropriate use them. This strengthens, again, how important it is to improve approaches for increasing the behavior of seatbelt use. According seatbelt use in China. to a National Safety Council report, the rate of seatbelt use in the As anticipated, our study results showed that when Chinese United States rose from 69% in 1998 to 83% in 2008, and much of drivers have better attitudes toward the importance of using seat- that rise is attributed to the enactment of seatbelt laws in 49 states, belts, they are more likely to wear seatbelts and have fewer traffic with seatbelt use being 10% higher in states with primary enforce- violations and car crashes. The relationships between safety atti- ment (National Safety Council, 2010). The top two reported reasons tudes, safety behaviors, and safety outcomes are consistent with for why Chinese drivers do not wear seatbelts, “too much trouble” prior published research. For example, according to the Theory of and “uncomfortable,” may suggest a need to improve the comfort of Planned Behavior (Ajzen, 1988, 1991), attitudes influence behavior. the actual seatbelt system. Anthropometry may be used to exam- Chinese drivers’ attitudes and perceptions toward seatbelt use pre- ine whether the current seatbelts used in China are appropriate dict drivers’ actual behavior of wearing seatbelts and subsequent for Chinese drivers’ or passengers’ body size. Efforts may include experience of car crashes and traffic violations. It is important to designing a more comfortable, easy-to-use seatbelt system for Chi- identify ways to improve the attitudes and behavior of seatbelt use. nese drivers. It may also be a matter of conveying to drivers the For example, public education may be used to change attitudes; law increased level of safety offered by seatbelts as a way to decrease enforcement and increased penalties may change behaviors. the perception of seatbelts being “too much trouble” to wear. If The current study has several limitations. First, although this people are made aware of the risks of not wearing seatbelts, they study collected data from multiple cities using multiple sources, may be more willing to ignore the discomfort. thus improving on prior studies using a single method (e.g., obser- Our results also showed that several personal and demographic vation studies) in one location (e.g., one large city), we were able to characteristics other than attitudes are correlated to seatbelt use collect data in only five cities in China due to practical constraints rates in China. By combining both observation and self-reported and to focus on contacting drivers only at gas stations. Even though data, the study results (see Table 2 for univariate analyses and the ranges of the response rates (79–83%) for these five various Tables 5 and 6 for multivariate analyses) provide some evidence size cities in the current study seem reasonable, China is a large that being an older driver, being a female, having a higher education country and there may be rather significant differences between level (which may be a potential factor for socioeconomic status), regions. Future research may collect data from an expanded range living in larger cities, and being a professional driver, as well as hav- of cities/regions and in various situations (e.g., highway versus local ing a better attitude toward the importance of wearing seatbelts, roads) in order to provide more generalizable information. Caution were correlated with greater seatbelt use, although no significant needs to be used when generalizing the data from the current study relationships were found between years of driving, annual driving to the whole country. Second, in the study survey, attitude was distance, and the use of seatbelts. The results are similar to those measured using only one item. If more generalized data is needed in prior studies conducted in various countries (e.g., Bendak, 2005; in future studies, multiple-item scales can be created to measure Li et al., 2006; Lund, 1986; Reinfurt et al., 1996; Wells et al., 2002). more precisely the attitudes of the Chinese regarding seatbelt use These data can be used to answer the question “Who should be in their country. Third, future studies should move on to conduct in the targeted group when conducting seatbelt interventions in interventions targeting improved seatbelt use in China. Stevenson China?” Without further information, we are not able to provide et al.’s (2007) intervention study, which combined health promo- actual reasons why people with certain characteristics have better tion, training and law enforcement improvement, was a good start. or worse seatbelt use rates. The results of the study, however, sug- The use rate of 62% found in their intervention city, considered low gest that there may be a need to target people with specific personal when compared to most developed countries, is higher than all the characteristics when conducting seatbelt interventions in China. cities in the current study. Personal characteristics are important components of particular Furthermore, although it is a strength of the current study that theories that can be utilized to increase the use of seatbelts among two types of seatbelt use data were collected (i.e., self-reported 896 Y.-H. Huang et al. / Accident Analysis and Prevention 43 (2011) 889–897 seatbelt use and objective observation information) and results showed that Chinese drivers reported that for some specific situa- showed that there is a significant consistency between these two tions (e.g., driving on highways, urban roads or countryside roads), scores (r = .62, p < .01), both subjective and objective data have their their likelihood of using seatbelts were varied. strengths and weaknesses. In our case, even though the subjects In conclusion, this study employed multiple data collection themselves should know whether they wear seatbelts, some limi- methods (i.e., semi-structured interviews, observation, in-person tations with self-reported data (e.g., social desirability effects) may surveys) to explore seatbelt use in five cities in China. This study occur and the data need to be interpreted with caution. On the other suggests the probability of extremely low use of seatbelts for hand, even though it is good that the objective observation data of drivers, passengers, and children in China, corresponding with seatbelt use were also collected in the current study, bias may exist what we anticipated, and provides insight into the attitudes of as well since the data were collected only one time. Our results Chinese drivers on seatbelt use and potential interventions.

Appendix A. Survey Questions

Q1. Based on your observation and estimation, what is the percentage rate of seatbelt use for the following people) 1.1 general drivers of the car (%) 1.2 the front seat passenger (%) 1.3 the back seat passenger (%)

Q2. In general, what percentage of the time (%) is it that you will wear a seatbelt in the following situations? 2.1 you as the driver of the car (%) 2.2 you as the front seat passenger (%) 2.3 you as the back seat passenger (%)

Q3. If there are kids in your car, where do they usually sit? front seat; back seat; no consistency

Q4. If there are kids in your car, do they wear seatbelts in general? “Yes”: % of the time or “No”

Q5. Regarding factors affecting seatbelt use rate

Please evaluate the following driving situations and the likelihood that you will use a seatbelt. Then use “>”, “<” or “=” to compare the likelihood in each situation. “>” indicates that the seatbelt use rate of the prior factor is higher than the one after, and “<” indicates that the seatbelt use rate of the prior factor is less than the one after.

5.1. on an expressway/highway () on urban roads 5.2. on countryside roads () on urban roads 5.3. on a winding mountain road() on a straight, flat road 5.4. in bad weather (for example, snowing, raining, foggy) () in good weather 5.5. in very hot weather () when the weather temperature is nice 5.6. in very cold weather () when the weather temperature is nice 5.7. in day time () at night 5.8. driving to/from work during a weekday () driving for pleasure during the weekend 5.9. when the road surface is good () when the road surface is bad 5.10. when you drive alone () when there are other people in the car 5.11. when you see police officers are around () when you see no police are around 5.12. when you are driving for a long-distance travel () when you are driving for a short distance 5.13. when you know many other drivers in China are wearing seatbelts () when you know few other drivers in China are wearing seatbelts

Q6. Do you agree that it is important in general to wear a seatbelt when you drive a car? 1. Disagree 2. Somewhat Disagree 3. Neither agree or disagree 4. Somewhat Agree 5. Agree

Q7. Regarding the reasons why Chinese drivers wear seatbelts, what do you think the three most important reasons are? 1. already have the habit 2. avoid penalty 3. their families ask them to 4. their companies ask them to 5. safer 6. other reasons

Q8. Regarding the reasons why Chinese drivers don’t wear seatbelts, what do you think the three most important reasons are? 1. forget 2. uncomfortable 3. too much trouble 4. not needed at low speeds 5. only traveling short distances 6. don’t have the safety conscientious 7. when not moving in a traffic jam 8. trust their own driving skill and believe these is no need 9. other reasons

Q9. Regarding the best interventions to increase seatbelt use rate in China, what do you think the three most useful interventions are?

1. health promotion (for example, running television ads) 2. provide training (for example, strengthen the importance of using seatbelts in drivers’ training school) Y.-H. Huang et al. / Accident Analysis and Prevention 43 (2011) 889–897 897

3. enforcement improvement (for example, more executing/enforcement of the laws by police) 4. improve the design of seatbelts, make them more comfortable 5. add more safety signs on the side of the road to remind people about wearing seatbelts 6. improve seatbelt warning signals inside the car (will warn people if not wearing seatbelt) 7. increase the penalty for not wearing a seatbelt 8. promote/ask family and friends to encourage drivers to use seatbelts for safety 9. others

References Li, G.L., Li, L.P., Stevenson, M., Ivers, R., Zhou, Y., 2006. Roadside observations of the use of seatbelts in Guangzhou and Nanning cities, China. Chinese Journal of Epidemiology 27, 698–701. ACEA, 2010. European Automobile Manufactures’ Association, http://www.acea. Lund, A.K., 1986. Voluntary seat belt use among U.S. drivers: geographic, socioeco- be/index.php/news/news detail/production/. nomic, and demographic variation. Accident Analysis and Prevention 18, 57–64. Ajzen, I., 1988. Attitudes, Personality and Behavior. Dorsey, Chicago. Muchinsky, P.M., 1997. Psychology Applied to Work, 5th ed. Brook/Cole Publishing Ajzen, I., 1991. The theory of planned behavior. Organizational Behavior and Human Company, Pacific Grove, CA. Decision Processes 50, 179–211. National Highway Traffic Safety Administration (NHTSA), April 2009. Seat Belt Use in AUSTST, 2002. Annals of US Traffic Safety (Translation, published in Chinese). Traffic 2008—Use Rates in the States and Territories. (Research Note: DOT HS 811 106). Administration Research Institute of China State Security Ministry & Jiangsu National Center for Statistics and Analysis, Washington, DC, Available on-line University, Wuxi, Jiangsu, China. at: http://www-nrd.nhtsa.dot.gov/Pubs/811106.PDF (accessed 12.05.10). Babbie, E., 1995. The Practice of Social Research, 7th ed. Wadsworth Publishing National Highway Traffic Safety Administration (NHTSA), June 2009. Lives Saved in Company, Belmont, CA. 2008 by Restraint Use And Minimum Drinking Age Laws (Research Note: DOT HS Bandura, A., 1977. Social Learning Theory. Prentice Hall, Englewood Cliffs, NJ. 811 153). National Center for Statistics and Analysis, Washington, DC, Available Bendak, S., 2005. Seatbelt utilization in Saudi Arabia and its impact on road accident on-line at: http://www-nrd.nhtsa.dot.gov/Pubs/811153.PDF. injuries. Accident Analysis and Prevention 37, 367–371. National Safety Council, 2010. Seat belts. NSC, Washington, DC, Available CAAM, 2010. China Association of Automobile Manufacturers’ Statistics Report, Bei- on-line at: http://www.nsc.org/Safety road/DriverSafety/Pages/SeatBelts.aspx jing, China. (accessed 12.05.10). Cooper, P.J., 1994. Estimating overinvolvement of seat belt non-wearers in crashes Passmore, J., Ozanne-Smith, J., 2006. Seatbelt use amongst taxi drivers in Beijing, and the effect of lap/shoulder restraint use on different crash severity conse- China. International Journal of Injury Control and Safety Promotion 13 (3), quences. Accident Analysis and Prevention 26 (2), 263–275. 187–189. CRTAS, 2002. China Road Traffic Accidents Statistics. Traffic Administration Bureau Peden, M., Scurfield, R., Sleet, D., Mohan, D., Hyder, A.A., Jarawan, E., Mathers, C. of China State Security Ministry, Beijing, China. (Eds.), 2004. World report on road traffic . World Health Orga- CRTAS, 2003. China Road Traffic Accidents Statistics. Traffic Administration Bureau nization (WHO), Geneva. of China State Security Ministry, Beijing, China. Preusser, D.F., Williams, A.F., Lund, A.K., 1991. Characteristics of belted and unbelted Eby, D.W., Molnar, L.J., Olk, M.L., 2000. Trends in driver and front-right passenger drivers. Accident Analysis and Prevention 23, 475–482. safety belt use in Michigan: 1984–1998. Accident Analysis and Prevention 32, Reinfurt, D.W., William, A.F., Wells, J.K., Rodgman, E., 1996. Characteristics of drivers 837–843. not using seat belts in a high belt use states. Journal of Safety Research 27, Eby, D.W., Vivoda, J.M., 2003. Driver hand-held mobile phone use and safety belt 209–215. use. Accident Analysis and Prevention 35, 893–895. Routley, V., Ozanne-Smith, J., Li, D., Yu, M., Wang, J., Zhang, J., Tong, Z., Wu, M., Wang, Eby, D.W., Vivoda, J.M., Fordyce, T.A., 2002. The effects of standard enforce- P., Qin, Y., 2008. China belting up or down? Seatbelt wearing trends in Nanjing ment on Michigan safety belt use. Accident Analysis and Prevention 34, and Zhoushan. Accident Analysis and Prevention 40, 1850–1858. 815–823. Routley, V., Ozanne-Smith, J., Qin, Y., Wu, M., 2009. Taxi driver seat belt wearing in European Transportation Safety Council, 1996. Seatbelts and Child Restraints: Nanjing, China. Journal of Safety Research 40 (6), 449–454. Increasing Use and Optimizing Performance. European Transportation Safety Stevenson, M., Yu, J., Ying, Z., Hendrie, D., Ivers, R., Li, L.P., Norton, R., 2007. China Council, Brussels, . Seatbelt Intervention, http://www.thegeorgeinstitute.org/shadomx/apps/fms/ Evans, L., 1987. Belted and unbelted driver accident involvement rates compared. fmsdownload.cfm?file uuid=C1624211-E2D3-643F-551E- Journal of Safety Research 18, 57–64. C2E82BA2A5AC&siteName=iih. Evans, L., 1996. Safety-belt effectiveness: the influence of crash severity and selective The Central People’s Government of the People’s Republic of China, 2010. recruitment. Accident Analysis and Prevention 28 (4), 423–433. http://www.gov.cn/banshi/2005-08/23/content 25575 2.htm (in Chinese). Filde, B., Fitzharris, M., Vulcan, P., Koppel, S., 2004. Benefits of Retrofitting Seat- The Ministry of Public Security of the People’s Republic of China, 2010. belt Reminder Systems to Australian Passenger Vehicles. Monash University http://www.mps.gov.cn/n16/n1282/n3493/n3823/n442207/2245672.html (in Accident Research Center, Clayton, Victoria. Chinese). Fleiter, J.J., Gao, L.P., Qiu, C., Shi, K., 2009. Availability, functionality, and use of seat- The World Bank, 2010. 2010 World Development Indicators, Chapter 2. People, 2.1 belts in Beijing taxis prior to the Beijing Olympic Games. Accident Analysis and Population dynamics. The World Bank, Development Data Group, Washington, Prevention 41, 342–344. DC. Available at http://data.worldbank.org/sites/default/files/section2.pdf. Forjuoh, S.N., 2003. Traffic-related injury prevention interventions for low-income Transport Canada, 2000. Results of Transport Canada’s July 2000 Survey of Seatbelt countries. Injury Control and Safety Promotion 10 (1–2), 109–118. Use in Canada. Leaflet RS2000-02 E, Ottawa, Ontario. Forjuoh, S.N., Li, G., 1996. A review of successful transport and home injury inter- Vivoda, J.M., Eby, D.W., Kostyniuk, L.P., 2004. Differences in safety belt use by race. ventions to guide developing countries. Social Science and Medicine 43 (11), Accident Analysis and Prevention 36, 1105–1109. 1551–1560. Wang, Z., Jiang, J., 2003. An overview of research advances in road traffic trauma in Hu, G., Wen, M., Baker, T.D., Baker, S.P., 2008. Road-traffic deaths in China, China. Traffic Injury Prevention 4 (1), 9–16. 1985–2005: threat and opportunity. Injury Prevention 14, 149–153. Wells, J.K., Williams, A.F., Farmer, C.M., 2002. Seat belt use among African Americans, Huang, Y.H., Zhang, W., Roetting, M., Melton, D., 2006. Experiences from dual- Hispanics, and Whites. Accident Analysis and Prevention 34, 523–529. country drivers: driving safely in China and the US. Safety Science 44, World Health Organization, 2009. Global Status Report on Road Safety: Time for 785–795. Action, http://whqlibdoc.who.int/publications/2009/9789241563840 eng.pdf. Kopitis, E., Cropper, M., 2005. Traffic fatalities and economic growth. Accident Anal- Zhang, W., Huang, Y.H., Roetting, M., Wang, Y., Wei, H., 2006. Driver’s views and ysis and Prevention 37, 169–178. behaviors about safety in China: what do they NOT know about driving? Acci- Koushki, P.A., Bustan, M.A., Kartam, N., 2002. Impact of safety belt use on road acci- dent Analysis and Prevention 38 (1), 22–27. dent injury and injury type in Kuwait. Accident Analysis and Prevention 35 (2), Zhou, Y., Baker, T.D., Rao, K., Li, G., 2003. Productivity losses from injury in China. 237–241. Injury Prevention 9, 124–127.