Highway Safety Behavioral Strategies for Rural and Tribal Areas: A Guide (2023)

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13   Guidance on Identifying, Selecting, and Adapting Countermeasures and Strategies After completing an assessment and identifying priorities, you are ready to identify potential countermeasures and strategies to address each priority. In general, there are multiple counter- measures and strategies to choose from. However, not all of them may be suitable for your community—perhaps one requires too much funding, or you do not have access to the focus audience (e.g., to implement a school-based program). Therefore, after identifying potential countermeasures and strategies, you will need to select one or more that are appropriate and feasible to implement. Once you have selected a countermeasure or strategy, you may need to adapt it to your local setting. You will want to do this in a way that maintains effectiveness; otherwise, you might implement a countermeasure or strategy and have no impact. Developing a logic model for your countermeasure or strategy can guide selection and successful adaptation. To begin, this chapter explores the differences between how behavioral and engineering coun- termeasures and strategies work. Next, it provides guidance on identifying, selecting, and adapt- ing countermeasures and strategies. General Behavioral and Engineering Approaches In general, behavioral countermeasures and strategies improve roadway safety by changing people’s decisions about driving behavior. Examples include driving after drinking (impaired driving), using a cell phone while driving (distracted driving), or using a seat belt (occupancy protection), as well as many other behaviors. Table 3 describes four basic approaches that behavioral countermeasures and strategies use. In contrast, engineering countermeasures and strategies improve roadway safety by chang- ing the physical environment in ways that change people’s behavior and reduce negative con- sequences when people make mistakes (Table 4). Unlike behavioral countermeasures and strategies, these countermeasures only have an impact on people’s behavior in a specific place (where the design exists), and they do not require changing people’s beliefs to achieve changes in behavior. Some behavioral countermeasures and strategies change behavior that would come before and lead to risky driving. For example, reducing underage drinking reduces impaired driving among underage youth; that is, when fewer youth drink, fewer youth drive after drinking. Similarly, training servers in restaurants and bars that serve alcohol about not providing too many drinks to an individual (i.e., overserving) reduces impaired driving. Identifying and addressing such related behavior that may contribute to risky driving is a way to expand your efforts and increase effectiveness. C H A P T E R   4

14 Highway Safety Behavioral Strategies for Rural and Tribal Areas: A Guide General Approach How It Works Examplesa Laws, policies, rules Laws, policies, and rules establish clear expectations about acceptable behavior. They also enable enforcement and establish penalties for not complying. • Laws such as seat belt use requirements, speed limits, and graduated driver’s licenses • Workplace policies about never using a cell phone while driving • Family rules about never driving after drinking Enforcement and adjudication Enforcement of laws may increase people’s belief that they will be caught and prosecuted if they violate the law. • High-visibility enforcement campaigns such as Click-It-or- Ticket • Teaching law enforcement officers how to detect impaired drivers • Teaching prosecutors how to successfully prosecute an impaired driving case Education Media campaigns or educational experiences change people’s understanding or beliefs about certain behavior. • Drivers’ education to teach people how to drive safely • Education campaigns about the dangers of distracted driving • Seat Belt Convincer, which allows people to experience the force of a low-speed collision to give them an understanding of what can happen in a crash when they do not use a seat belt Intervention Interventions are focused efforts with people who have engaged in risky behavior or who are about to engage in a risky behavior. • Creating an impaired driving court that includes treatment and monitoring for people arrested for impaired driving • Using alcohol ignition interlocks to prevent impaired driving • Promoting bystander engagement—positive intervention such as calling for a ride for someone who has been drinking or asking a person not to drive after drinking or using drugs aThese are examples and not meant to be recommendations. aThese are examples and not meant to be recommendations. General Approach How It Works Examplesa Roadway design Roadways can be designed in ways that constrain the behavior of road users to reduce crashes that result in serious injury or fatality. • Roundabouts to slow speeds and eliminate side- impact crashes • Pedestrian bump-outs to narrow roadways, slow speeds, and focus drivers on pedestrians • Speed bumps to slow speeds • Reduced conflict intersections to eliminate side-impact crashes • Separating nonmotorized users from vehicles Roadway treatment Surface treatments can be used to reduce loss of control or keep vehicles from leaving the roadway. • Rumble strips to reduce roadway departure or crossing the centerline • Reflectors and wider painted edge lines to reduce the incidence of vehicles leaving the roadway • High-friction surface treatments to prevent sliding and loss of control Managing energy Components that absorb energy when vehicles leave the roadway can be added and areas adjacent to the roadway can be cleared to reduce the severity of crashes. • Wire rope, guard rails, and impact devices that absorb energy and keep vehicles from crossing to oncoming vehicles, rolling over embankments, or colliding with fixed objects • Clearing trees from the edge of roadways Table 4. Ways that engineering countermeasures and strategies change people’s behavior or reduce negative consequences. Table 3. Ways that behavioral countermeasures and strategies change people’s behavior.

Guidance on Identifying, Selecting, and Adapting Countermeasures and Strategies 15   Guidance on Identifying Countermeasures and Strategies Reviewing countermeasures and strategies that have been used in other communities and the evidence for their effectiveness is very helpful when decisions are being made about which countermeasure or strategy to choose for your community. Box 5 lists various resources to help you identify potential countermeasures and strategies, and Appendix B provides examples of countermeasures and strategies implemented in nine rural settings. These examples may help you as you think about selecting and implementing countermeasures and strategies in your community. While it may seem easy, developing your own countermeasure or strategy to change behavior is not recommended. Changing people’s behavior is complex and difficult. Over the years, many strategies have been tried; most have been ineffective. Some have been harmful. It is far easier and more cost-effective to select a countermeasure or strategy that has been evaluated and shown to be effective. Box 5. Resources for Potential Countermeasures and Strategies Countermeasures That Work: A Highway Safety Countermeasure Guide for State Highway Safety Offices (10th ed.) (Venkatraman et al. 2021) https://www.nhtsa.gov/book/countermeasures/countermeasures-work This guide provides a description of each countermeasure, the costs and time to implement it, the evidence supporting it, and references. The guide is not intended to be a comprehensive list of countermeasures available for use. The topic areas addressed include alcohol- and drug-impaired driving, seat belts and child restraints, speeding and speed management, distracted driving, motorcycle safety, young drivers, older drivers, pedestrian safety, bicycle safety, and drowsy driving. Appendix C of the present report includes a list of behavioral countermeasures and strategies referenced in Countermeasures That Work that have strong or moderate levels of evidence that they are effective. Proven Safety Countermeasures https://safety.fhwa.dot.gov/provencountermeasures/ This website allows users to filter engineering countermeasures and strategies on the basis of geography, road classification, focal area (e.g., roadway departure, intersection, pedestrian), average daily traffic, problem, and crash type. It includes a webinar, training video, and overview flier. A guidance document (available as a PDF) is provided for each countermeasure or strategy. Many countermeasures are suitable for rural and tribal settings. Appendix D of the present report lists engineering countermeasures and strategies referenced in Proven Safety Countermeasures, all of which have evidence of effectiveness. FHWA’s Roadway Safety Data Program Toolbox https://safety.fhwa.dot.gov/rsdp/toolbox-home.aspx This resource will help your organization build a new roadway safety data program or strengthen an existing one. Options are “Manage,” “Analyze,” “Collect,” and “Research.” The website is a database of multiple resources that is searchable by filters, and there is a filter for “local/rural” under “focus area.” There is no filter for “tribal.” There is also a 98-page primer to guide users. (continued on next page)

16 Highway Safety Behavioral Strategies for Rural and Tribal Areas: A Guide Box 5. Resources for Potential Countermeasures and Strategies (Continued) What Works Fact Sheet: Motor Vehicle-Related Injury Prevention (Community Guide 2022) https://www.thecommunityguide.org/resources/what-works-motor-vehicle -related-injury-prevention.html In addition to this fact sheet, the Community Guide website (https://www .thecommunityguide.org) has a searchable database of recommendations from the findings of the Community Preventive Services Task Force, including 28 recommendations under “Motor Vehicle Injury” (other topics include mental health, violence, and nutrition). Most of the 28 recommendations focus on alcohol, and there are also recommendations on seat belts, child safety seats, and motorcycle helmets. Resources include policy and law recommendations as well as a brochure summarizing motor vehicle safety information from the larger Guide to Community Preventive Services.  Selected Evidence-Based Strategies for Preventing Injuries (IHS 2021) https://www.ihs.gov/sites/injuryprevention/themes/responsive2017/display _objects/documents/IHS_IPP_Evidence-based_Strategies.pdf This document outlines strategies and interventions recommended by the Indian Health Service Injury Prevention Program for working with tribal communities. The guidance will help users identify and select the most appropriate evidence- based or promising strategies for reducing or preventing unintentional and intentional injuries in specific community settings, including those related to crashes. The document identifies three core strategies to improve roadway safety: car seat use, seat belt use, and the prevention of impaired driving. For each strategy, it provides a few bullet points supporting the strategy and then a table of specific interventions for implementing the strategy (along with their level of evidence). Evidence-Based Behavior Change Campaigns to Improve Traffic Safety Toolkit https://aaafoundation.org/evidence-based-behavior-change-campaigns-to -improve-traffic-safety-toolkit/ This hands-on resource from the AAA Foundation for Traffic Safety will help practitioners develop behavior change campaigns that are evidence-based and effective. It includes information and resources to plan, design, implement, and evaluate behavior change campaigns. Community-Based Toolkit for Road Safety Campaigns https://tirf.ca/projects/community-based-toolkit-road-safety-campaigns/ This toolkit from the Traffic Injury Research Foundation will support communities in effectively developing and delivering their own road safety campaigns. Included are (1) a summary of research on road safety campaigns, the evidence base, and theoretical approaches guiding the development of campaigns and (2) a collection of fact sheets created by experts in social marketing, research, and evaluation to support full implementation of a campaign. 

Guidance on Identifying, Selecting, and Adapting Countermeasures and Strategies 17   Box 5. Resources for Potential Countermeasures and Strategies (Continued) Rural Intelligent Transportation System Toolkit https://ruralsafetycenter.org/rural-intelligent-transportation-system-its-toolkit/ This toolkit from the National Center for Rural Road Safety offers a series of 42 fact sheets (PDFs) on critical needs in rural transportation categorized by topic for transportation practitioners. The fact sheets provide introductory summary information to help agencies identify areas in which they can improve efficiency and safety on roadways, public transportation systems, and nonmotorized systems. It is designed to help rural agencies face their unique challenges, such as extreme weather events, congestion from special events, or seasonal recreational travel. All the content is relevant to rural settings and could be adapted to tribal settings. Rural Transportation Toolkit https://www.ruralhealthinfo.org/toolkits/transportation The Rural Health Information Hub website is a compilation of “promising” models and resources for transportation programs in rural communities, including resources and information on development, implementation, evaluation, and sustainment of rural transportation programs. It primarily focuses on transportation systems and developing or enhancing options in rural communities. There is one subsection on road safety focused on design and infrastructure. A Guide to Implementing Child Passenger Safety Inspection Stations (Ostergaard and Guzzetta 2021) https://rosap.ntl.bts.gov/view/dot/55179/dot_55179_DS1.pdf This guide provides recommendations for implementing child passenger safety inspection stations. Inspection stations are an effective way to increase the proper use of car seats, booster seats, and seat belts. This guide is intended for all those looking to implement an inspection station in their community. Substance Abuse and Mental Health Services Administration https://www.samhsa.gov/ The Substance Abuse and Mental Health Services Administration website includes several resources relevant to roadway safety: • Drug-Free Workplace Toolkit (to reduce impaired driving), • Preventing Marijuana Use Among Youth (to reduce impaired driving), • Supported Education Evidence-Based Practices Kit (to promote cultural competency of roadway safety efforts and assessments of fidelity as strategies/countermeasures are adapted to rural or tribal settings), and • Healthy People 2030: Injury Prevention (Objective: transportation), a national plan supporting rural roadway safety practitioners by connecting rural roadway safety to national health priorities as well as data and evidence- based resources and strategies. (continued on next page)

18 Highway Safety Behavioral Strategies for Rural and Tribal Areas: A Guide Box 5. Resources for Potential Countermeasures and Strategies (Continued) America’s Rural Roads: Beautiful and Deadly (GHSA 2022) https://www.ghsa.org/resources/GHSA/Rural-Road-Safety22 This report from the Governors Highway Safety Association provides general guidance for rural communities on ways to improve rural road safety. Resources Related to Farm Equipment and Roadway Safety • Lighting and Marking of Agricultural Equipment on Highways: Summary of ASAE Standard S279.181 [Gorucu et al. (2021), https://edis.ifas.ufl.edu /publication/AE175]. Research has shown that following lighting guidelines for farm equipment reduces crashes. This report provides lighting guidance. • “Raising Awareness of Farm Equipment on Public Roadways in Tennessee” [Mehlhorn et al. (2017) https://elibrary.asabe.org/abstract.asp?AID=48579]. Tennessee created an educational program for young drivers about the laws and guidelines pertaining to farm equipment on public roadways. This study showed that the program did increase students’ knowledge. • Find Me Driving (https://findmedriving.com/). Several soybean producers sponsored this educational effort, which provides safety tips about driving around farm equipment in the form of posters, brochures, training, and videos. No research is available about the program’s effectiveness. Resources Related to Amish Populations and Roadway Safety • “Designing an Agricultural Safety Intervention Program for Ohio Amish Youth” [Beaudreault et al. (2009) https://www.researchgate.net/publication /240630122_Designing_an_Agricultural_Safety_Intervention_Program_for _Ohio_Amish_Youth_CASES]. Amish youth may be exposed to risks associated with farming. This paper reviews an approach to providing education to this community. • Horse and Buggy Driver’s Manual [Pennsylvania DOT (n.d.-a) https://www.dot .state.pa.us/public/PubsForms/Publications/PUB%20632.pdf]. The Pennsylvania DOT created this guidance for those using horse-drawn buggies. • Safe Driving in Amish Country [Pennsylvania DOT (n.d.-b) https://www.dot .state.pa.us/public/PubsForms/Publications/PUB%20627.pdf]. The Pennsylvania DOT developed this fact sheet to educate the general public about driving in areas where horse-drawn buggies may be likely. • Amish Roadway Safety Program (https://agsafety.osu.edu/program-areas /amish-roadway-safety-program). The Ohio State University Extension created this series of fact sheets on a variety of topics on Amish roadway safety. Resources Related to All-Terrain Vehicle Safety • The All-Terrain Vehicle (ATV) Safety Institute has a variety of resources available at https://atvsafety.org/. • The U.S. Consumer Product Safety Commission has a public service announce- ment on ATV safety at https://www.cpsc.gov/Safety-Education/Safety-Educa- tion-Centers/ATV-Safety-Information-Center. • The 4-H program for youth (often supported by Extension Agents) has an ATV safety program: https://atv-youth.org/.

Guidance on Identifying, Selecting, and Adapting Countermeasures and Strategies 19   Guidance on Selecting Countermeasures and Strategies Guidance on selecting strategies is often included in the resources listing countermeasures and strategies as well as in the planning processes described in Chapter 3. Selecting counter- measures and strategies that have been shown to be effective is more likely to lead to improving roadway safety in your community than designing your own countermeasure or strategy. As you consider a particular countermeasure or strategy, you may want to create a logic model for it (see Chapter 2). This will help you determine whether the countermeasure or strategy is a good fit for your setting. Factors to keep in mind when you are selecting strategies can be categorized by general approach: laws, policies, and rules; enforcement and adjudication; educa- tion; and intervention. Laws, policies, and rules: • Not all local jurisdictions may be able to enact new laws. Check with your local prosecutor to learn more. • Getting support from your local prosecutor and judges is important. Law enforcement officers are less likely to enforce laws unless they know prosecutors and judges will follow up. • Workplaces provide important opportunities to enhance roadway safety by enacting policies about roadway safety. These could address a variety of behavior, such as seat belt use, distracted driving, speeding, and even driving after drinking or using drugs (e.g., marijuana). Workplace policies should be coupled with training to make them more effective. Some workplaces will champion their role in improving roadway safety. Idaho Power’s work to promote workplace policies on distracted driving is one example (see https://www.idahopower.com/outages-safety /safety/driving-safety/). • Consider approaching public workplaces as well (e.g., local government, schools) Often these organizations are significant employers in rural and tribal settings. • Promoting family rules can be an effective way to promote important conversations about roadway safety in the home and establish clear expectations for all family members. Schools, faith communities, and local parenting resources may offer information on promoting family rules on roadway safety. Enforcement and adjudication: • Local enforcement resources may be limited. Consider partnering with state patrols and even agencies in adjacent counties for special enforcement activities. • Sometimes, local law enforcement agencies can be hesitant to enforce roadway safety laws. Seek to elevate the voices of concerned stakeholders to support enforcement. Emphasize that the desired outcome is not more citations but compliance and safer outcomes. • Seek training for officers to bolster their skills. Reach out to your state’s DOT about training opportunities for Drug Recognition Expert (DRE), Advanced Roadside Impaired Driving Enforcement (ARIDE), Below 100, and other resources. • Most states have Traffic Safety Resource Prosecutors who provide training on effective prosecu- tion of impaired driving cases. The contact for each state can be found at the National Traffic Law Center (https://ndaa.org/programs/ntlc/traffic-safety-resource-prosecutor-list/). • Review the examples shared at the end of this chapter for more ideas. Education: • The most common reason education campaigns do not work is lack of dosage. Dosage describes how much of the focus population the education reaches, how often it reaches them, and for how long. Effective education requires significant dosage. Ask yourself: “Are we a mile wide and an inch deep?” If so, consider how you can narrow the focus population or obtain more resources.

20 Highway Safety Behavioral Strategies for Rural and Tribal Areas: A Guide • Engaging teachers can help make educational efforts more successful. Teachers know what is developmentally appropriate for different ages and what is required to transfer knowledge. • Often, rural and tribal settings do not have extensive budgets for campaigns. Having a diverse coalition supporting the campaign can increase the dosage. Consider creating speaking points, social media posts, posters, and so forth that everyone can share through their contacts. Intervention: • DUI courts have been shown to be effective. However, starting one requires time and com- mitment. Reach out to your state DOT for resources on how to start a DUI court in your community. • Alcohol ignition interlocks have been shown to be effective for preventing alcohol-impaired driving. However, they can be expensive and require regular maintenance. Rural and tribal settings may need to partner with neighboring communities to implement ignition interlocks. Reach out to your state DOT for resources on how to get started. • Training people who work in restaurants and bars about not overserving alcohol can reduce impaired driving. This training may also include teaching servers how to intervene and encourage alternative transportation for individuals who have been drinking. Reach out to local law enforcement or substance use prevention coalitions in your community or neigh- boring communities to find someone who can provide beverage server training. You can also get local law enforcement officers trained so that they can provide the training locally. Guidance on Adapting Countermeasures and Strategies Some countermeasures and strategies may need to be modified or adapted to be implemented in your setting. You want to minimize any changes that you make, because each change could reduce effectiveness. Developing a logic model for the countermeasure or strategy will help you understand how the strategy works. You can then carefully decide what changes you might need to make and consider whether these changes may adversely affect the likelihood of achieving the desired short-term outcomes. Here are four reasons you may need to adapt a countermeasure or strategy: 1. You may need to change some of the content of materials to better reflect your community. This could involve changing such things as images, words, examples, or language. However, you want to make sure that your changes do not change the underlying meaning. For example, an image used in a print advertisement for a local newspaper shows a scene from a city. You recognize that most people in your community would not connect with that image, so you work with a local graphic artist to change the image to a scene more like your community. 2. You may need to change the language (or just certain words) as well as the reading level to better align with your focus audience. For example, a program designed for high school students cannot be used with elementary students without significant changes. Elementary students may not even be developmentally ready for such a program. Working with teachers and others would be important. 3. Your community may not have the same resources as described in the countermeasure or strategy. For example, you may not have a local television or radio station to share important messages. You would then need to identify other ways to get messages to most people in your community. Simply skipping this component could significantly reduce effectiveness. 4. It can be tempting to change or remove core components because people do not like them, do not know how to implement them, or do not have the time. These kinds of changes could significantly reduce effectiveness and should be considered very carefully. For example,

Guidance on Identifying, Selecting, and Adapting Countermeasures and Strategies 21   a program developed for schools may require 10 sessions; however, the school says it only has time for one session and would prefer to do it in an assembly with all students. This kind of change could make the program completely ineffective. In such a case, you should consider finding another program or spend more time advocating for the school to invest in the 10 sessions. One Technique for Adapting Countermeasures and Strategies: Red Light, Yellow Light, Green Light Before considering changes to a countermeasure or strategy, you could use a stoplight approach to categorize each component or part of a countermeasure or strategy. Green-light components are those in which changes would not meaningfully change the countermeasure or strategy and are therefore acceptable. Yellow-light components are those in which minor changes would be unlikely to meaningfully change the countermeasure or strategy, and changes should be care- fully explored to ensure they do not reduce effectiveness. Red-light components are those critical parts that cannot be changed, as changes would be likely to reduce effectiveness or are known to do so. Your task force or coalition could consider each potential change and the component(s) it would affect and discuss whether they considered it a green, yellow, or red-light change. Box 6 provides resources for adapting evidence-based countermeasures and strategies. Box 6. Resources for Adapting Evidence-Based Countermeasures and Strategies Rural Health Information Hub https://www.ruralhealthinfo.org/toolkits/rural-toolkit/2/adapting-interventions The Rural Health Information Hub provides a toolkit for choosing strategies as well as guidance for adapting strategies to fit local needs. The toolkit provides considerations for the types of proposed adaptations as well as components that should not be altered. Making Adaptations Tip Sheet (ACF n.d.) https://www.acf.hhs.gov/sites/default/files/documents/prep-making-adaptations -ts_0.pdf This resource from the Administration for Children and Families, U.S. Department of Health and Human Services, describes why and when strategies could be adapted and provides guidance on the core components of evidence-based strategies that must remain intact. “Adapting Evidence–Based Behavioral Interventions for New Settings and Target Populations” (McKleroy et al. 2006) https://prevention.ucsf.edu/sites/prevention.ucsf.edu/files/inline-files /CDCMapofAdaptationProcess%28MAP%292006.pdf This paper provides practitioners with a systematic approach to identifying the most appropriate intervention for their population and capacity, monitoring the process, and evaluating the outcomes of the adapted intervention. (continued on next page)

22 Highway Safety Behavioral Strategies for Rural and Tribal Areas: A Guide A Story of Adapting a Pedestrian Safety Audit A rural community wanted to conduct an audit to assess pedestrian safety and accessibility. They needed to select a tool that both met their project goals and could be implemented with the community’s capacity and resources. Many of the tools they reviewed contained the same categories: sidewalk conditions, street crossings and intersections, driver behavior, safety, and comfort. They maintained these core components but modified the specific questions in each category to better align with a rural area. For example, a question about whether a transit station had shelter was replaced with a ques- tion about availability of benches or places to rest (because this community did not have transit stations). The underlying purpose of the question—assessing the comfort of the area—was maintained, but the question was more appropriate and meaningful for their setting. They also added questions such as “Is there an audible pedestrian signal?” and “If there is an audible pedestrian signal, does it give a pedestrian enough time to cross?” based on the needs of local stakeholders concerned about people with visual impairments. Box 6. Resources for Adapting Evidence-Based Countermeasures and Strategies (Continued) Community Toolbox https://ctb.ku.edu/en/table-of-contents/analyze/choose-and-adapt-community -interventions/cultural-adaptation/main The Community Toolbox is a free online resource for communities working to improve health. Chapter 19, Section 4 “Adapting Community Interventions for Different Cultures and Communities” provides information about why and when cultural adaptations may be necessary as well as helpful resources to guide communities in that process. Adapting Evidence-Based Practices for Under-Resourced Populations (SAMHSA 2022) https://www.samhsa.gov/resource/ebp/adapting-evidence-based-practices-under -resourced-populations This publication describes a variety of adaptations for evidence-based practices for under-resourced populations and provides steps to engage in the adaptation process. The guide also provides research supporting such adaptations.