BEHAVIOR MODIFICATION / July 2001Pastò, Baker / INCREASING SEAT BELT USE

The authors evaluated a brief intervention for increasing seat belt use among the front seat occu- pants of cars at a junior college, in a jurisdiction with a mandatory belt use law. The intervention included public posting of performance feedback and distribution of an informational flyer to cars in a target parking lot. Feedback was the display of the proportion of drivers observed wear- ing seat belts on the previous observation day. Seat belt use among drivers increased from 64% during the baseline phase to 71% during the intervention phase. Seat belt use among front pas- sengers increased from 49% during the baseline phase to 67% during the intervention phase. In both cases, seat belt use at follow-up was comparable to seat belt use during the intervention phase, although a trend toward decreasing belt use was noted. Also found was higher seat belt use among females as compared with males irrespective of their front seat occupant status (driver or passenger). Effects of the intervention are discussed in the context of increasing seat belt use in a hardcore nonuser population of predominantly young adults.

Evaluation of a Brief Intervention for Increasing Seat Belt Use

on a College Campus

LUIGI PASTÒ Defence and Civil Institute of Environmental Medicine

ANDREW G. BAKER McGill University

A large proportion of car occupants does not use seat belts, despite their proven effectiveness in reducing the likelihood of injury and death in traffic accidents (Conn, Chorba, Peterson, Rhodes, & Annest, 1993; Smith-Seemiller, Lovell, Franzen, Smith, & Townsend, 1997) and the enforcement of mandatory belt use laws (Dee, 1998; Thyer &

471

AUTHORS’ NOTE: This project was partially supported by scholarships from the Fonds pour la Formations de Chercheurs et l’aide à la Recherche du Québec and the Ontario Graduate Scholar- ships Program to Luigi Pastò. We thank the students, faculty, and staff of Vanier College in Mon- treal, Canada, for their participation. We also thank Megan Thompson, Valérie Gil, Pierre Mercier, Ross Pigeau, Joe Baranski, and two anonymous reviewers for helpful comments on ear- lier drafts of this article. Please send correspondence to Luigi Pastò, Defence and Civil Institute of Environmental Medicine, 1133 Sheppard Avenue West, P.O. Box 2000, Toronto, Ontario, Canada, M3M 3B9; e-mail: [email protected].

BEHAVIOR MODIFICATION, Vol. 25 No. 3, July 2001 471-486 © 2001 Sage Publications

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Geller, 1990). There is evidence that resistance to mandatory belt use laws reflects a hardcore nonuser population also characterized by a greater frequency of other risk behaviors (Foss, Beirness, & Sprattler, 1994; Hunter, Stutts, Stewart, & Rodgman, 1990). Among this pre- sumably hardcore nonuser population are young adults who are both least likely to wear seat belts (Clark, 1993; Reinfurt, Williams, Wells, & Rodgman, 1996; Wilson, 1990), and more likely than older adults to be involved in traffic accidents (Hunter et al., 1990; Miller, Lestina, & Spicer, 1998). In this article, we evaluate the effectiveness of a brief intervention to increase seat belt use among predominantly young adults above that achieved with a mandatory belt use law.

Behavioral interventions for increasing seat belt use may include extrinsic or intrinsic incentives. Extrinsic incentives emphasize exter- nal, tangible inducements and include stepped-up enforcement of mandatory belt use laws or monetary incentives (Hagenzieker, Buleveld, & Davidse, 1997; Johnston, Hendricks, & Fike, 1994). Monetary incentives may involve immediate rewards, such as cash, and delayed rewards, such as sport tickets or chances to win a lottery (Hagenzieker et al., 1997). Interventions for increasing seat belt use that include extrinsic incentives are effective across a broad range of populations and contexts (Hagenzieker et al., 1997; Johnston et al., 1994). Interventions that promote the acquisition of internal justifica- tions for performing a target behavior are typically characterized as involving intrinsic incentives (Thyer & Geller, 1990). Examples of interventions with primarily internal incentives are participative goal setting (e.g., Ludwig & Geller, 1997), awareness and consensus build- ing sessions (e.g., Kelo, Geller, Rice, & Bryant, 1988; Ludwig & Geller, 1991), public information and education (e.g., Hunter, Stew- art, Stutts, & Marchetti, 1993), and posting of group performance feedback (e.g., Malenfant, Wells, Van Houten, & Williams, 1996). These interventions differ from those involving primarily extrinsic incentives as behavior change is presumed to occur as a consequence of the internalization of behavior-consistent attitudes and standards of conduct. For example, group performance feedback may invoke social comparison processes through which behavior-consistent atti- tudes and standards of conduct are internalized and consequently modify behavior. Conformity pressure in the direction of seat belt use

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emerges from the social comparison process itself rather than from any external incentive such as a threat of punishment or a monetary reward.

Despite the effectiveness of interventions with extrinsic incentives, there are reasons why researchers and policy makers alike may wish to focus on intrinsically based programs. First, in a review of seat belt promotion programs, Geller, Rudd, Kalsher, Streff, and Lehman (1987) reported that interventions with and without extrinsic incen- tives have similar immediate impacts on seat belt use but that the maintenance of behavior change appears to be greater following inter- ventions without extrinsic incentives (Cope, Grossnickle, & Geller, 1986). Second, interventions for increasing driving-related safety behaviors with intrinsic incentives often result in the generalization of behavior changes to other driving-related behaviors (e.g., Ludwig & Geller, 1991; Streff, Kalsher, & Geller, 1993). For example, Ludwig and Geller (1997) reported that a participative goal setting interven- tion for car stops increased the target behavior, as well as turn signal and seat belt use. Finally, those who are at a relatively high risk of car accidents, such as younger drivers, appear to be more responsive to interventions with intrinsic incentives as compared to interventions with extrinsic incentives. For example, mandatory belt use laws appear to be least effective among younger drivers (Dee, 1998; Tipton, Camp, & Hsu, 1990). Ludwig and Geller (1991) assessed the effec- tiveness of an intervention that consisted of the participation in a seat belt awareness session, as well as the signing of a buckle-up promise card. Postintervention seat belt use among drivers younger than 25 years of age increased by about 50% as compared to baseline use. In contrast, seat belt use among drivers older than 25 years of age was unaffected by the intervention (Ludwig & Geller, 1991).

INTERVENTION AND RATIONALE

The objective of this report is to evaluate the effectiveness of a two-component intervention for increasing seat belt use among front seat occupants of cars using one target parking lot on the campus of a junior college. The intervention included both the public posting of performance feedback and the distribution of an informational flyer

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among a sample of predominantly young adults and adolescents. Although the separate and combined effects of performance feedback and public information on seat belt use have been evaluated in previ- ous reports, their effect on the seat belt use of younger car occupants is unknown.

Public posting of performance feedback typically includes display of the proportion of drivers observed performing a target behavior in a previous observation period (e.g., Van Houten & Nau, 1981). Perfor- mance feedback has been shown to promote a number of safety behav- iors including the following: seat belt use (Grant, Jonah, Wilde, & Ackersville-Monte, 1983), slower driving (Van Houten & Nau, 1981; Van Houten, Nau, & Marini, 1980), and greater compliance with workplace safety guidelines (Sulzer-Azaroff & De Santamaria, 1980). Malenfant et al. (1996) assessed the effect of a road-side sign provid- ing belt use rates to car occupants in two cities where a belt use law was in force. Seat belt use in both cities increased reliably above an already high baseline use rate of more than 70%. Grant (1990) evalu- ated a seat belt promotion program that included both feedback and education components in a jurisdiction with a belt use law. Seat belt use at the intervention site increased by 26% for drivers and by 65% for passengers as compared to the seat belt use at a control site (Grant, 1990). The effect of performance feedback on seat belt use appears to be greatest in jurisdictions with a mandatory belt use law and where the majority of car occupants wear seat belts (Grant et al., 1983).

It remains unclear if public posting can increase belt use among younger adults above that achieved with a mandatory belt use law. Pre- vious reports on the effect of performance feedback on seat belt use have been conducted among predominantly older drivers. For exam- ple, in the report by Grant (1990), 95% of the participants targeted by the public posting intervention were older than 25 years of age. As younger car occupants are more likely to be involved in traffic acci- dents and less likely to wear seat belts as compared to older occupants (Miller et al., 1998; Reinfurt et al., 1996), evaluating the effect of seat belt promotion interventions among this presumably hardcore non- user population is desirable. Accordingly, the current intervention occurred among participants who were predominantly younger than 25 years of age.

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The performance feedback component of the intervention was sup- plemented by the distribution of an informational flyer to cars in the target parking lot. The flyer informed car occupants about the nature and goal of the investigation under way and also provided feedback on the change in seat belt use that occurred between the baseline and the intervention phases. Although information is typically considered to be insufficient on its own to motivate behavior change, it may be a nec- essary prerequisite (Grant et al., 1983). Consequently, providing information is often one of several components of a seat belt promo- tion program that also includes incentives or enhanced enforcement of mandatory belt use laws (e.g., Decina, Temple, & Dorer, 1994; Hunter et al., 1993; Kay, Sapolsky, & Montgomery, 1995; Williams, Hall, Tolbert, & Wells, 1994).

Information approaches to reducing risk behaviors are predicated on the assumption that people will behave in a fashion to increase the likelihood of personal safety if provided with the appropriate informa- tion and behavioral options (Thyer & Geller, 1990). When assessed independently of incentives or enforcement, public information inter- ventions result in only very modest increases in seat belt use (Johnston et al., 1994). The effectiveness of public information appears related to the frequency of exposure to the informational sources. For exam- ple, the modest effects of mass media campaigns on the frequency of risk behaviors is often attributed to limited exposure (Gantz, Fitzmaurice, & Yoo, 1990). To maximize any direct behavioral response, the informational flyer was distributed to every car in the target parking lot three times during a 5-day intervention phase, each time during peak hours of parking lot use.

METHOD

PARTICIPANTS AND SETTING

The participants in this study included drivers and front passengers of cars that used one parking lot on the campus of Vanier College in Montreal during a 4-week period of the winter academic term. The parking lot could accommodate approximately 300 cars and had only

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one access point. An attendant was stationed in a booth at the entrance of the parking lot during business hours, and cars entering or exiting the lot first came to a full stop at the attendant’s booth before proceed- ing. At the time of this study, a belt use law was in effect in the prov- ince of Québec, with a $25 fine for violators. No comparable seat belt promotion program was ever attempted at the college.

The front seat occupants of 2,285 cars were observed during the course of the study, resulting in 2,285 observations of driver belt use and 660 observations of front passenger belt use. Consistent with pre- vious reports (Williams et al., 1994), the age of front seat occupants was estimated according to broad criteria to minimize error (i.e., < 25, 25-45, > 45). Table 1 lists the number and percentage of participants by occupant status (driver, front passenger), gender, and estimated age. The age distribution of participants is consistent with the status of Vanier as a junior college, which provides preuniversity degrees as well as professional diplomas primarily to recent high school graduates.

OBSERVATION PROCEDURES AND DATA COLLECTION

One observer recorded shoulder belt use, gender, and estimated age of front seat occupants on a portable tape recorder from within the parking lot attendant’s booth. A pilot study demonstrated that data obtained with this procedure are reliable, which also ensured unobtru- sive observations.

Eighteen observation sessions were conducted during the 4-week duration of the study. Cars were observed exiting the parking lot from 15:30 to 17:30 during each day of the study. These observation times represented the period of greatest traffic flow from the parking lot. In addition, probe observation sessions were conducted of cars entering the parking lot from 07:00 to 09:00 on two occasions: one on the last day of the first week and the other on the last day of the second week of the study. These sessions were to ensure that the seat belt use observed between 15:30 and 17:30 accurately represented the use rate of people using the parking lot throughout the day. Observations during the probe sessions were obtained at an intersection of a public street and the private road leading to the target parking lot. The entrance of the

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parking lot and the feedback sign were not visible from this location. Observations were not taken on weekends.

Weather and road conditions were noted throughout the 4-week duration of the study. The pavement was wet, due to a light drizzle, on 4 of the 6 observation periods during the first week of the study (i.e., baseline phase). Wet road conditions, without precipitation, were noted on 2 of 12 observation periods conducted from the 2nd to the 4th week of the study, one in each of the intervention and follow-up phases.

EXPERIMENTAL PHASES

Baseline. During baseline, shoulder belt use, gender, and estimated age of the front seat occupants of cars were recorded during the obser- vation sessions for 5 consecutive days (i.e., Monday to Friday) according to the procedure outlined above. Five daily observation ses- sions were conducted from 15:30 to 17:30, and a probe observation session was conducted from 07:00 to 09:00 on the Friday of this week. Only administrative personnel, who granted permission to conduct this study, and the parking lot attendant were aware of the data collec- tion under way.

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TABLE 1 Number and Percentage of Observations by Occupant Status

(Driver, Front Passenger), Gender, and Estimated Age

Estimated Age (years) < 25 25-45 > 45 Total

# % # % # % # %

Driver Female 817 36 153 7 59 3 1029 45 Male 915 40 209 9 132 6 1256 55 Total 1732 76 362 16 191 8 2285 100

Front passenger Female 309 47 24 4 8 1 341 51 Male 289 44 18 3 12 2 319 49 Total 598 91 42 6 20 3 660 100

NOTE: Percentages are calculated relative to front seat occupant status. Percentage totals may not sum accurately due to rounding.

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Intervention. During the intervention, the sampling of shoulder belt use, gender, and estimated age of front seat occupants proceeded as during baseline for 5 consecutive days of the 2nd week of the study (i.e., Monday to Friday). During this period, two different intervention components were implemented simultaneously: a) public posting of the seat belt use rate of drivers using the lot on the previous observa- tion day, and b) distribution of an informational flyer to all the cars within the parking lot at prescribed times.

A feedback sign, placed adjacent to the entrance of the parking lot, indicated the percentage of drivers wearing a seat belt on the previous observation day. Cars entering the parking lot came to a full stop at the attendant’s booth approximately 6 meters away from the sign. The sign measured 46 cm wide and 91 cm high and was fastened to a stand approximately 2 meters above the ground. The reflective lettering on the sign measured approximately 6 cm wide and 9 cm high, and the message read “DRIVERS WEARING SEAT BELTS YESTERDAY, XX%.” The actual rate indicated on the sign was changed daily to reflect the percentage of drivers observed to be wearing seat belts on the previous observation day. The sign was erected on the 2nd day of the intervention phase and remained there for 4 consecutive days until the end of this phase.

Flyers were distributed to all cars in the parking lot on the 1st, 3rd, and 5th days of the intervention phase (Monday, Wednesday, and Fri- day). A total of 284 flyers was distributed on Monday, 102 flyers on Wednesday, and 261 flyers on Friday. The distribution occurred at 11:30 on each of the 3 days, when the parking lot contained the great- est number of cars. Flyers were placed under the driver side wind- shield wiper of the cars, ensuring both visibility and accessibility by the driver.

The flyer was divided into four different content areas. The first area presented a message in bold print stating “SEAT BELTS SAVE LIVES. BUCKLE UP PLEASE.” The second area presented fatality and injury rates due to car accidents in Québec and a statement of the effectiveness of seat belts in reducing fatalities and injuries in car acci- dents. The third content area contained the message “Whether or not you wear a seat belt may be your own business, but tell that to the fam- ily and friends of someone who has been injured in a car accident.”

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The content of the fourth area of the flyer was changed between the first 2 days of distribution and the 3rd day. During the first 2 distribu- tion days, the fourth content area advised the reader that the safety belt use of people using the parking lot was being monitored and explained the purpose of the feedback sign. On the 3rd day of distribution, the fourth content area provided feedback on the actual change in seat belt use that occurred between the baseline phase and the intervention phase.

Follow-up. During this phase, the sampling of shoulder belt use, gender, and estimated age of front seat occupants proceeded as before on the 3rd and 4th weeks of the study, with the exception that a probe observation session was not conducted. Observations during this phase were interrupted by school holidays. Consequently, observa- tions for the follow-up phase were conducted on the first 2 days of the 3rd week of the study (Monday and Tuesday) and the last 4 days of the 4th week (Tuesday, Wednesday, Thursday, and Friday). During this phase, the feedback sign was not present and no flyers were distributed.

RESULTS

On the 2 days that included probe sessions, observations were made from 07:00 to 09:00 and from 15:30 to 17:30. Belt use during these two different observation periods was equivalent. Consequently, data for these two observation periods were pooled for the subsequent discussion.

Results from the seat belt observations are considered separately for the data that included all the cars (n = 2,285) and for the subset of the data that included cars with both a driver and a front passenger (n = 660).

DRIVER BELT USE

The overall rate of seat belt use among drivers across experimental phases was 68%, and more female drivers wore seat belts than did

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male drivers (female drivers’ belt use = 75%, male drivers’ belt use = 63%). Figure 1 displays the rate of driver belt use in each of the three experimental phases. Inspection of this figure reveals that driver belt use was higher during the intervention phase of the experiment (71%) relative to driver belt use during the baseline phase (64%), represent- ing a relative increase in seat belt use of about 11%. Although driver belt use remained higher during the follow-up phase (68%) relative to the baseline phase, there appeared a tendency for driver belt use to decline between intervention and follow-up phases.

FRONT PASSENGER BELT USE

The overall rate of seat belt use among front passengers across experimental phases was 59%, and more female front passengers wore seat belts than did male front passengers (female passengers’ belt use = 66%, male passengers’ belt use = 52%). Figure 2 displays the rate of front passenger belt use in each of the three experimental phases. Inspection of this figure reveals a similar pattern of observed seat belt use as described above for drivers. Passenger belt use was higher during the intervention phase of the experiment (67%) relative to passenger belt use during the baseline phase (49%), representing a relative increase of about 37%. Passenger belt use during the fol- low-up phase (61%) was lower than passenger belt use during the intervention phase, but remained about 25% higher relative to the baseline phase.

DISCUSSION

In this article, we evaluated a brief intervention for increasing seat belt use among front seat occupants of cars on the campus of a junior college. The combination of public posting of performance feedback and the distribution of an informational flyer effectively increased the seat belt use both of drivers and of front passengers. The belt use rate of drivers increased by about 11% following the intervention phase, whereas the belt use of front passengers increased by about 37%, rela- tive to the baseline phase. In both cases, belt use at follow-up was com-

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parable to belt use during the intervention phase, although a trend toward decreasing belt use was noted.

These findings are important in light of two predominant consider- ations. First, the observed increases in seat belt use were obtained

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Figure 1. Rate of driver belt use in each of the three experimental phases (number of observations: Baseline = 739, Intervention = 869, Follow-up = 677).

Figure 2. Rate of front passenger belt use in each of the three experimental phases (num- ber of observations: Baseline = 222, Intervention = 236, Follow-up = 202).

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among participants who were not previously complying with a man- datory belt use law. The minority of car occupants who do not comply with belt use laws are thought to be part of a hardcore nonuser popula- tion also characterized by other risk behaviors. For example, nonuse of seat belts is related with poorer driving records, larger consumption of alcohol, and increased likelihood of having an arrest record (Dee, 1998; Foss et al., 1994; Hunter et al., 1993; Hunter et al., 1990; Reinfurt et al., 1996; Wilson, 1990). Second, the participants in this study were predominantly young adults who are among the least likely to wear seat belts (Clark, 1993; Schootman, Fuortes, Zwerling, Albanese, & Watson, 1993; Wilson, 1990). It was estimated that 76% of drivers and 91% of front passengers observed in this study were younger than 25 years of age. Consequently, increases in seat belt use observed with the current intervention occurred among predomi- nantly younger drivers and front passengers whose behavior is most resistant to change (Dee, 1998; Reinfurt et al., 1996).

The positive effects of the intervention, however, are tempered by one other finding. The seat belt use of drivers during the follow-up phase (68%) was between their belt use rate during the intervention (71%) and baseline (64%) phases. Gains in seat belt use were clearly maintained at follow-up relative to the baseline phase only among front passengers. However, this finding may be more striking because of a much lower baseline belt use among front passengers as com- pared to drivers. Driver belt use at baseline was already 64%. In com- parison, belt use among front passengers was only 49% during the baseline phase. In general, significantly less baseline belt use among passengers than drivers is consistent with previous reports (e.g., Grant, 1990; Malenfant et al., 1996).

Also consistent with previous reports is that seat belt use was greater among females than among males irrespective of their front seat occupant status. Among drivers, seat belt use for females was 75% as compared with 63% for males. Among passengers, 66% of females and only 52% of males wore seat belts. Females are typically reported to have higher belt use rates than males during both baseline and follow-up phases of intervention programs (Johnston et al., 1994). As this intervention occurred in a jurisdiction with a mandatory belt use law, this finding is also consistent with reports that males are less

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responsive to belt use laws than are females (Dee, 1998; Hunter et al., 1990; Tipton et al., 1990).

The effect of performance feedback on seat belt use may have been mediated by at least two separate processes (Grant et al., 1983). As already considered in the introduction to this article, performance feedback may present car occupants with a group standard against which their own behavior is compared. According to social compari- son theory (Festinger, 1954), people tend to compare themselves with their peers and to bring their behavior more in line with the group stan- dard or norm. In the face of evidence that a majority of drivers use seat belts, nonusers may change their behavior to conform with the major- ity. In the current report, driver belt use was consistently higher than 60%, and any conformity pressure was in the direction of belt use from the outset of the intervention phase. The effect of the performance feedback on seat belt use may also be extrinsically motivated. The mere presence of performance feedback implies that individual behavior is monitored. Implied surveillance may motivate seat belt use particularly in a jurisdiction with a belt use law, where police offi- cers are the most likely surveillants. Car occupants, then, may wear seat belts to avoid receiving a traffic fine. Consequently, the context in which the current intervention was implemented provided the two conditions that are most favorable to the effective use of performance feedback: (a) initial belt use rate greater than 50%, and (b) enforced mandatory belt use law. In this context, both social comparison and implied surveillance may have contributed to increasing the observed seat belt use.

The effect of the current intervention among participants estimated to be predominantly younger than 25 years of age is consistent with evidence that feedback of seat belt use may be selectively effective among younger drivers. Grant et al. (1983, Experiment 1) reported that a feedback sign increased seat belt use only among younger driv- ers (i.e., younger than 25 years of age). However, as seat belt use among the participants in Grant et al.’s experiment was consistently less than 50%, the extent to which social comparison mediated the effect of their intervention is unclear. More generally, age differences in the effect of performance feedback may be consistent with the notion that social comparison is implicated. This is because younger

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persons may be more likely to conform than older persons when faced with conformity pressure (e.g., Pasupathi, 1999), and the use of social comparison itself may decline with age (Gibbons & Gerrard, 1997). To the extent that the effect of performance feedback is at least partly mediated by social comparison, this intervention may be selectively targeted at younger drivers who have the greatest to benefit from increased seat belt use.

Although the current findings suggest that posting of performance feedback is an effective method of increasing seat belt use among younger adults, these findings must be considered in light of a major methodological consideration. The two components of the interven- tion described in this article (i.e., posting of performance feedback, and distribution of an informational flyer) were implemented simulta- neously. Consequently, the differential effect of each component on the observed seat belt use could not be assessed. The assumption in the previous discussion is that the posting of performance feedback was the primary active component in the intervention package. This assumption is based on the finding that public information interven- tions result in only very modest increases in seat belt use when assessed independently of other treatment components (Johnston et al., 1994). As the resources and effort required to implement each of the two components of the current intervention package differed greatly, future investigations could be designed to directly assess their relative effectiveness.

In sum, an intervention with performance feedback increased seat belt use among predominantly young adults (i.e., younger than 25 years of age), who are both less likely to wear seat belts and more likely to be involved in traffic accidents as compared to older adults (Dee, 1998; Miller et al., 1998). Although the absolute increase in driver seat belt use following the intervention was modest, it occurred in a presumably hardcore nonuser population who would benefit most from increased seat belt use. Brief interventions with performance feedback may be a cost-effective method for promoting seat belt use in institutional settings and with younger persons whose behavior is refractory to mandatory belt use laws and who are at greater risk of traffic accidents.

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Luigi Pastò is an experimental psychologist at the Defence and Civil Institute of Environ- mental Medicine in Toronto, Canada. He received a B.A. and an M.A. in psychology from McGill University and a Ph.D. in clinical psychology from the University of Ottawa. His research interests include large-scale modification of health-related behaviors, stress management, and judgment and decision-making processes.

Andrew G. Baker is a professor in the Department of Psychology at McGill University.

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