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Strategies to Address SharedRisk and Protective Factorsfor Driver SafetySEPTEMBER 2019

About the Safe StatesAllianceThe Safe States Alliance is a national non-profit organization and professional associationwhose mission is to strengthen the practice of injury and violence prevention.To advance this mission, Safe States Alliance engages in activities that include: Increasing awareness of injury and violence throughout the lifespan as a public healthproblem; Enhancing the capacity of public health agencies and their partners to ensure effectiveinjury and violence prevention programs by disseminating best practices, setting standardsfor surveillance, conducting program assessments, and facilitating peer-to-peer technicalassistance; Providing educational opportunities, training, and professional development for thosewithin the injury and violence prevention field; Collaborating with national organizations and federal agencies to achieve shared goals; Advocating for public health policies to advance injury and violence prevention; Convening leaders and serving as the voice of injury and violence prevention programswithin state health departments; and Representing the diverse professionals within the injury and violence prevention field.For more information about the Safe States Alliance, contact the national office:Safe States Alliance5456 Peachtree Blvd. #244Atlanta, Georgia 30341770.690.9000www.safestates.orgThe resource document, Strategies to Address Shared Risk and Protective Factors for Driver Safety, wasdeveloped with support from a cooperative agreement (DTNH22-17-H-00030) between the Safe StatesAlliance and the National Highway Traffic Safety Administration (NHTSA).Disclaimer: The opinions, findings, and conclusions expressed in this publication are solely those ofthe contributors. They do not necessarily represent the official positions of the Safe States Alliance, theNational Highway Traffic Safety Administration (NHTSA), or any agencies with which individual contributors are affiliated.Recommended Citation:Safe States Alliance. (2019). Resource Document: Strategies to Address Shared Risk and ProtectiveFactors for Driver Safety. Atlanta, GA: Safe States Alliance.a2Strategies to Address Shared Risk & Protective Factors for Driver Safety

AcknowledgementsThis resource document was developed with contributions from the Behavioral Health Workgroup,a group comprised of key subject matter experts from the fields of injury and violence prevention,behavioral health, behavior change, psychology, traffic safety, and population health from nationalorganizations, state agencies, federal agencies, and the research community. The Workgroup, ledby a Chairperson, convened in person and over the phone between January 2018 and June 2019 tocontribute to this work. Members of the workgroup included:Ginna JonesShannon Brietzman, MA (Workgroup Chair)PrincipalHealth Management AssociatesPatrick Carter, MDMotor Vehicle Safety CoordinatorColorado Department of Public Health andEnvironmentAssistant Professor, Department of EmergencyMedicine; Assistant Director, University ofMichigan Injury Prevention CenterAnnie KirkLaura Dunn, MPH, CPST-IJ. Peter Kissinger (deceased)Highway Safety SpecialistNational Highway Traffic Safety AdministrationOffice of Occupant ProtectionMighty Fine, MPH, CHESDirector, Center for Public Health Practice andProfessional DevelopmentAmerican Public Health AssociationTara GillSenior Director Advocacy and State LegislationAdvocates for Highway and Auto SafetySharon Gilmartin, MPHDeputy DirectorSafe States AllianceConsultantRetired, AAA FoundationJennifer Martin, MSWManager, Injury and Violence Prevention ProjectIllinois Department of Public HealthEileen M. McDonald, MSSenior ScientistJohns Hopkins Center for Injury Research and PolicyJohns Hopkins Bloomberg School of Public HealthIna Robinson, MPH (Technical Writer)Program ManagerSafe States AllianceStephanie ShawTony GomezManager, Violence and Injury PreventionPublic Health – Seattle & King CountyProject Director, Seattle/King County Target ZeroTraffic Safety Task ForceJessica HopkinsViolence and Injury Prevention Program ManagerPublic Health – Seattle and King CountyRegional Program ManagerNational Highway Traffic Safety Administration,Region 5Safety AdvocateNational Transportation Safety BoardDavid Sleet, PhDSenior Researcher and Traffic Safety ConsultantTJFACT (Formerly at CDC)Merissa A. Yellman, MPHEpidemiologist, Synergy America, Inc.National Center for Injury Prevention and Control;Centers for Disease Control and Prevention (CDC)This resource document is dedicated to the memory of our colleague, J. Peter Kissinger, whopassed away in February 2019. His significant contributions to the transportation safety field havebeen paramount and his direct contributions to the Behavioral Health Workgroup were highlyinstrumental toward framing the content in this document.Report design and layout: Julie Alonso, Safe States AllianceStrategies to Address Shared Risk & Protective Factors for Driver Safetya3

Table of ContentsPreface .2Executive Summary .3Intended Audience .6Methods .9Public Health Approach .10Burden of Motor Vehicle-related Injuriesand Fatalities .12Key Definitions .14Shared Risk and Protective Factors Acrossthe Social Ecological Model .16Shared Risk and Protective Factors Approachto Driver Safety .18Shared Risk and Protective Factors AcrossDriving Behaviors .19Behavior Change Strategies and Interventions .27Limitations of the Report .39Recommendations .41References .46Appendix A: Problem Identification Guide .55Appendix B: Exploring Key Factors ofRisky Driving Behaviors .60a4Strategies to Address Shared Risk & Protective Factors for Driver Safety

List of Tables and FiguresFiguresFigure 1. Social Ecological Model .16TablesTable 1. Level of Social Ecology andCorresponding Definitions .17Table 2. Shared Risk Factors AcrossDriving Behaviors .20Table 3. Shared Protective Factors AcrossDriving Behaviors .24Table 4. Distinguishing Among Levels of Evidence .28Table 5. Behavior Change Strategies and Interventionsto Promote Driver Safety .30Table 6. Resources Related to Identifying, Monitoring,and Evaluating Risky Driving Behaviors .55Strategies to Address Shared Risk & Protective Factors for Driver Safety1

PrefaceMotor vehicle-related fatalities and injuriescould be significantly reduced if provenstrategies to reduce risky driving behaviorswere widely adopted and implementedacross the United States. Given the scarcityof resources and competing issues in thepublic health injury prevention and trafficsafety communities, practitioners have theopportunity to have the biggest impactby applying evidence-based strategies totraffic safety challenges that also addressshared risk or protective factors amongdifferent audiences. The Behavioral HealthWorkgroup (Workgroup) examined sharedrisk and protective factors across a set of riskydriving behaviors and then compiled a listof evidence-based strategies that successfully address those factors. Strategies usedto address these same risk and protectivefactors when applied to other high-riskhealth behaviors were considered for application to reducing risky driving behaviors.The emphasis on shared risk and protectivefactors provides opportunities for publichealth and transportation safety agencies towork collaboratively across sectors to maximize impact and leverage funds efficiently.This approach also emphasizes the socialdeterminants of health, recognizing that2individuals’ behaviors and environmentsinfluence their decision-making across thelifespan. The Workgroup focused their activities on the following topic areas related torisky driving behavior: aggressive driving and speeding, alcohol-impaired and other drug-impaireddriving, distracted driving, drowsy and fatigued driving, and seat belt nonuse by adults.The recommendations, developed fromcollaborative contributions of the BehavioralHealth Workgroup, bring a new perspectiveto traffic safety efforts by promoting behaviorchange strategies and interventions thatreduce known risk factors and/or strengthenprotective factors associated with safedriving behavior. This resource documentprovides a foundation to expand effortsbeyond high-visibility enforcement toward apopulation-based behavior change modelthat addresses factors at the individual,relationship, community, and societal levels.Strategies to Address Shared Risk & Protective Factors for Driver Safety

Executive SummaryMotor vehicle crashes currently rank as thesecond leading cause of death and the fourthleading cause of injury among the adultpopulation (National Center for Statistics andAnalysis, 2018). Because motor vehicle-related deaths affect the young, they are alsoresponsible for significant years of productive life lost. Rather than focusing specificallyon the driving behaviors themselves, thisresource document examines underlying riskfactors (e.g., those that make it more likelyfor an individual to engage in risky drivingbehaviors) and protective factors (e.g., thosethat make it more likely for an individual toengage in safe driving behaviors) to identifyhigh-leverage opportunities for reducingthe burden of motor vehicle-related injuriesand fatalities. These approaches extendbeyond the individual-level to include anunderstanding of the interconnectedness ofsocial elements in an environment across thelifespan. These approaches also highlighteffective strategies for facilitating behaviorchange and for the use of data to supportsurveillance and evaluation activities.The purpose of this resource is toprovide public health and trafficsafety professionals with recommendations for: applying the shared riskand protective factors approach toreduce risky driving behavior, identifying interventions that can addressthese risk and protective factors toprevent motor vehicle-related injuries and fatalities, and utilizing dataresources to measure the impact ofthese strategies.To achieve this purpose, a variety of conceptsare presented throughout the report,including: A brief overview of how the public healthapproach is a useful framework for investigating and understanding the causes ofmotor vehicle-related injuries and fatalities(p.10). Key definitions of risk factors, protectivefactors, behavior change strategies, andevidence-based strategies that have beenadapted from agencies that representinternational and federal-level perspectives on public health, mental health, andpublic safety (p. 14). An explanation of the benefits associatedwith connecting shared risk and protectivefactors across the various levels of socialecology, including broad examples ofstrategies that can address risk factors andpromote protective factors within eachlevel of the social ecological model (p. 16). An explanation of how to apply the sharedrisk and protective factors approach todriver safety to address multiple healthoutcomes across the lifespan of an individual (p. 18). A shared risk factors grid that observes thetrends that exist among the social ecological model and displays the connectionsbetween risk factors and unsafe drivingbehaviors (p. 20). A shared protective factors grid thatobserves the trends that exist among thesocial ecological model and displays theconnections between protective factorsand driving behaviors (p. 24). An explanation of how behavior changecan occur when aligning evidence-basedstrategies to a shared risk and protectivefactors approach, including guidance ondistinguishing between levels of evidence,tailoring interventions or strategies to theStrategies to Address Shared Risk & Protective Factors for Driver Safety3

specific needs of an individual or population group, and a table of evidence-basedstrategies that specifically address riskydriving behaviors and promote driversafety (p. 27). A collection of recommendations withspecial emphasis on applying a sharedrisk and protective factors approach topromoting safe and healthy driving practices (p. 41). A problem identification guide highlighting the role of data in demonstratingtrends in motor vehicle-related injuriesover time and a table of resources relatedto identifying, monitoring, and evaluatingrisky driving behaviors (p. 55). An exploration of key factors that impactrisky driving behaviors, including underlying causes that influence such behaviors(p. 60).Summary of RecommendationsRecommendations for