International Journal of Academic Medicine

: 2018  |  Volume : 4  |  Issue : 2  |  Page : 98--104

Postcollision safety device compliance in trauma patients

Irina Catanescu1, Meredith Meyer2, M Chance Spalding3, M Shay O'Mara4,  
1 OhioHealth Grant Medical Center; OhioHealth Doctors West Hospital, Columbus, Ohio, USA
2 University of Michigan, Ann Arbor, Michigan, USA
3 OhioHealth Grant Medical Center; OhioHealth Doctors West Hospital, Columbus; Ohio University College of Osteopathic Medicine, Athens, Ohio, USA
4 OhioHealth Grant Medical Center, Columbus; Ohio University College of Osteopathic Medicine, Athens, Ohio, USA

Correspondence Address:
Dr. Irina Catanescu
Trauma Services at Grant Medical Center, 111 S Grant Ave., Columbus, OH, 43215


Background: Noncompliance with established prevention measures (seat belts/helmets) continues to be prevalent. Research has shown three primary methods of increasing compliance: legislation, education, and postcollision intervention. We hypothesized that after a motor vehicle collision (MVC) or motorcycle crash (MCC), there are higher rates of safety device noncompliance and this behavior will not align with the benefits of prevention. The study of these patterns will, therefore, provide insight for interventions and education. Materials and Methods: This was a prospective, survey-based study of 165 patients performed during June–July 2016 at a Level 1 trauma center. Inclusion criteria consisted of adults involved in either MCC or MVC. Study groups consisted of the MVC and MCC cohorts and those compliant and noncompliant with safety devices. Outcomes were analyzed by comparison of demographics, injury severity score, self-reported safety device use, and substance abuse. Answers given to the final open-ended question of the survey were sorted based on subject matter as it related to reasoning of safety device use. Results: Seat belt users (71.3%) were older (46 vs. 39 years, P = 0.038) and had fewer passengers (1.5 vs. 2.2, P = 0.012). Helmet wearers (30.6%) were more likely women (odds ratio: 9.6, P = 0.009) and less likely to have a positive blood alcohol concentration (BAC) (59.1% vs. 100.0%, P = 0.01). Primary reasons for seat belt use were habit, safety, and law, while primary reasons for helmet use were safety and habit. Overall noncompliant individuals from both MCC and MVC cohorts were more likely to have a positive BAC. Conclusions: Noncompliant patients' reasoning was contradictory to the known benefit of safety restraints. Primary prevention device use relies on establishing habit and perceived safety. Through the postcollision survey, we were able to gather more insight for lack of compliance and this behavioral pattern. Immediate intervention allowed for an opportunity in safety education. Benefit was noted in patients' opportunity for self-reflection and willingness to change behavior. The following core competencies are addressed in this article: Patient care, Practice-based learning and improvement.

How to cite this article:
Catanescu I, Meyer M, Spalding M C, O'Mara M S. Postcollision safety device compliance in trauma patients.Int J Acad Med 2018;4:98-104

How to cite this URL:
Catanescu I, Meyer M, Spalding M C, O'Mara M S. Postcollision safety device compliance in trauma patients. Int J Acad Med [serial online] 2018 [cited 2022 Oct 2 ];4:98-104
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Full Text


Traffic accidents involving both motor vehicles and motorcycles continue to remain a significant health-care problem. According to the Centers for Disease Control (CDC) in 2015, close to half of collision fatalities occurred in unrestrained or unhelmeted patients.[1],[2] Seat belt use has shown to decrease mortalities by up to 65% and helmets reduce both head injuries (by 69%) and deaths (37%) as well.[3],[4],[5],[6] Even with current legislative enforcement, educational programs, and the established effectiveness of safety devices, the United States continues to lag behind other nations in compliance.[7]

Two effective methods of increasing compliance have been through legislation and educational programs. Stricter law enforcement of safety devices strongly correlates with reduction of morbidity and mortality.[3],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18] Although seat belt laws are prevalent in most states, only 19 states have helmet laws that require use in all operators and passengers (deemed “universal laws”).[18],[19] Partial law states show a compliance rate of 43%, universal law 80%, and overall rates of 61%.[18] Several states have changed to partial helmet laws resulting in a reported 50% fatality increase.[8],[20] Unfortunately, educational program development has been limited, and legislation trends have favored more lenient regulations.[5],[8],[12],[13],[14],[21],[22],[23],[24]

Some research has shown that alternative methods for improving safety can be used in postcollision settings. Although this patient group has been associated with higher rates of substance abuse, safety device noncompliance, and repeated collisions, educational interventions at the time of accident can have immediate effects on compliance and recidivism.[15],[25],[26] We designed our study to create a postcollision survey scenario with open-ended questions to better understand rationalization for noncompliance. We hypothesized that patients admitted to a Level 1 trauma center after a motor vehicle collision (MVC) or motorcycle collision (MCC) had higher rates of noncompliance with primary prevention measures than the general populous. We also postulated that reasoning for noncompliance would not correlate with the benefits of prevention and that our survey design could provide an avenue for immediate intervention.

 Materials and Methods

This was a prospective, survey-based study of postcollision adult trauma patients at a high-volume Level 1 trauma center in Columbus, Ohio. The study period was 2 months from June to July of 2016. Approval before data collection was designated by the Ohio Health Institutional Review Board, which governs research at the institution.

Inclusion criteria consisted of blunt trauma patients, age >18 years old, English speaking, and an injury mechanism of either MVC or MCC. Patients were excluded if they were determined to be in critical condition, discharged the same day of admission, or had potentially confounding psychological comorbidities (such as passenger death).

After explanation of the study and informed consent, patients gave verbal responses to a 17-question survey. Self-reported information collected from study participants included accident details such as speed limit, number of passengers, type of vehicle, and location. Demographics related to socioeconomic status and alcohol and illicit substance abuse were also reported. Full questionnaire is outlined in [Appendix 1]. The final question was open ended, inquiring why they either chose to use/abstain from the use of a safety device (motorcycle helmet or seat belt). Answers were recorded on a data collection sheet and categorized by subject matter as outlined in [Table 1]. All surveys were conducted by a single researcher over 2 months. Electronic medical record, institutional trauma database registry, and patient-reported survey answers were used for obtaining demographic variables of age, gender, status of passenger, or vehicle operator. Blood alcohol testing results and individual patient records were reviewed to ensure accuracy.{Table 1}[INLINE:1]

The overall cohort was divided based on patient involvement in either MVC or MCC. These groups were further subdivided based on their safety device adherence dubbed the compliant and noncompliant groups.

Outcomes were analyzed by comparison of demographics, injury severity score, self-reported safety device use, and blood alcohol concentrations (BAC) >0.010. Answers given to the final and open-ended question of the survey were sorted based on subject matter as it related to reasoning behind patient's safety device use.

Statistical analysis was performed by a trauma research biostatistician using the Statistical Analysis System (SAS) software (version 7, SAS Institute, Cary NC, USA). P value was defined as statistically significant if <0.05. Descriptive statistics were reported as means with standard deviations for continuous variables and frequencies with percentages for dichotomous/categorical variables. Percentages were compared between independent groups using Chi-square tests and logistic regression modeling. For continuous variables, means were analyzed between independent groups using two-sample t-tests or analysis of covariance modeling.


During the 1186 participants were evaluated for eligibility, 233 met our inclusion criteria, and of these, 190 were identified as having the mental and physical capacitance of undergoing a survey interview. A total of 165 patients consented and completed the survey.

When assessing demographics for the entire cohort, the average patient age was 43.1 (range 18–83) and the average age was similar between the MCC and MVC groups. Gender was found to be significant in collisions, and 59.4% were male (98 of n = 165) and 40.6% were female (P = 0.004). Remaining demographics did not statistically vary between these two groups [P < 0.050, [Table 2].{Table 2}

The MVC group (n = 129) was further broken down and analyzed in [Table 3] according to “compliant” seat belt users (71.3%, n = 92) and “noncompliant” (28.7%, n = 37). Two variables were found to be statistically significant age and number of passengers in the vehicle at the time of crash. Older patients (45.8 years) were significantly more likely to use a seat belt than their younger counterparts (38.9 years, P = 0.038). Similarly, seat-belted patients had less passengers when compared to the noncompliant groups (1.5 average passengers vs. 2.2, P = 0.012). The remaining variables (gender, location in vehicle, or intoxication) did not significantly correlate with seat belt use.{Table 3}

Of the 92 patients who wore a seat belt, 81 underwent a BAC test [Table 3]. An altered state, as determined by BAC >0.010, was positive in 16/81 or 19.8%. This finding was not statistically different from the noncompliant group where 21.9% (or n = 7/32) tested above a concentration of 0.010.

Motorcycle collision data showed that 30.6% or 11 of the 36 total patients were wearing a helmet and 25 or 69.4% were unhelmeted. When group demographics were analyzed, it was seen that women were 9.6 times more likely to wear their helmets than men (P = 0.009). The remaining variables of average age, location in vehicle, and number of passengers were not significant between the compliant and noncompliant groups [P < 0.05, [Table 4].{Table 4}

BAC was statistically higher in the noncompliant subgroup. 0 out of 9 BAC tests were positive in helmet wearers, compared to 48.0% or n = 12/25 in unhelmeted individuals (P = 0.01). There was also a statistically higher likelihood for compliant individuals (MCC and MVC) to have undetectable BACs (P = 0.03).

[Table 1] shows the tabulated answers to the open-ended survey. Individual answers are sorted by subject matter. The following reasons were given from compliant MVC patients for wearing their safety belts: habit (44%), safety (26%), and law requirements (25%) [Table 1]. Unrestrained individuals were unable to recall a particular reason for their noncompliance 46.0%, while the other two most common responses were discomfort and forgetting. This open-ended question prompted self-reflection in 13.5% of patients who indicated that they were going to wear seat belts in the future.

The most common reasons for motorcycle helmet use were safety (55%) and habit (36%). Only one response listed enforced legislation from other states in his transit as a reason for device use. Similar to responses of the MVC noncompliant group, very frequently, patients could not recall a particular reason for not wearing a helmet and realized that this decision was “bad” (44%). The survey prompted self-reflection, and 8% of patients stated that they will use a helmet going forward. Other answers included lack of comfort (36%), while 12% (n = 3/25) of participants commented on the laxity of Ohio helmet laws.


Our findings aligned with our hypothesis; the study population had lower rates of compliance when compared to the general public (nationally and locally), reiterating the at-risk behaviors for trauma patients.[5],[13] The reasoning for safety device use was similar in both the MCC and MVC groups: safety, habit, and legislation (more frequent in seat belt users). However, while the benefits provided by safety devices are inherent, this was not reflected in the rationalization for noncompliance. Both findings coincide with the limited data existing on post-MVC studies.[15]

The postcollision survey offered an opportunity for early education focused on safety and possibility for habit formation. The act of answering the questionnaire prompted self-reflection and commitment to behavior changes – an immediate effect. More importantly, this type of survey could be applicable to a larger trauma population and MCC patients as well.

Our study did have some discrepancies from the current literature. Usually, noncompliant groups are statistically younger, yet only our unrestrained MVC group followed this trend.[15] However, when both motorcycle and motor vehicle groups were analyzed, the noncompliant sidearm was statistically younger. This may be a reflection of our small study population of 25 noncompliant patients in the MCC group, possibly acting as a source for skewed data.

Literature shows strong correlations between collision rates, alcohol use, and safety device noncompliance.[15],[25],[26] We demonstrated similar findings when the MCC and MVC populations were analyzed together. Our noncompliant motorcycle operators correlated with more individuals having BAC concentrations >0.010. However, our MVC population had a similar number of individuals with higher BACs regardless of wearing a safety belt.

Our findings demonstrated that the postcollision questionnaire is an easily implemented intervention allowing for self-reflection and education. Furthermore, this tool is applicable to the trauma population that is known for accident recidivism and noncompliance. The interventional avenues that bolster compliance rates are education, state legislation, and early intervention. Safety and habit are the leading reasons for device compliance and should be stressed in early intervention and educational settings. Stricter legislation and enforcement in both helmet and safety belt compliance should be concomitantly pursued. Utilizing immediate postcollision interventions and capitalizing on this educational opportunity to emphasize safety and positive habit building is an easy initial step to increasing safety device compliance.

Limitations of our study include a small sample size. This could be rectified by future studies occurring for longer durations with emphasis on recruiting motorcycle accident victims. Determination of appropriate patient disposition for inclusion was at the discretion of the researcher which could be subject to selection bias. Due to the nature of survey studies, participants could have responded to researcher's questions with the “correct answer,” leading to response bias. Finally, admission in noncompliant patients to want to change their risky behavior does not guarantee a confirmatory change in their habit.

Future studies are needed to understand the benefit of postsurvey interventions, and prolonged study period of participants could follow recidivism rates and expand on small sample sizes.


Our study showed that safety and habit were the main reasons for helmet and seat belt compliance, while noncompliant reasoning was contradictory to the known benefit of these devices. Three methods of increasing compliance exist early intervention, legislation, and education. Through the use of a postcollision survey, we were able to provide immediate intervention and an opportunity for education on safety and habit building in a patient population that is known for accident recidivism and noncompliance. Future endeavors should continue to investigate legislation, education avenues, and early intervention, with particular focus on the potential for immediate impact on safety and habit building available to trauma patients before discharge.

Financial support and sponsorship


Conflicts of interest

There are no financial, personal or organizational disclosures to make by any of the authors that would influence this work or our conclusions. There are no conflicts of interest to disclose. This manuscript has been read and approved by all the authors, the requirements for authorship as stated in the journal guidelines have been met, and all authors believe the manuscript is representative of honest and original work.

Ethical conduct of research

All data was collected after institutional IRB approval, IRB study id # 14-0038. All study procedures were in accordance with the ethical standards of our institutional committee on human experimentation and with the Helsinki Declaration of 1975 and its revision in 2000. Informed consent was obtained on all participants. All participants were adults.


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