Original Article

The Effect of Educational Intervention Based on the Theory of Planned Behavior on the Seat Belt Use Behavior of Rural Adolescent Students

Please cite this article as follows: Mohammadian Y, Sadeghi-Bazargani H, Malekpour F, Jafari-koshki T, Rezapur-Shahkolai F. The effect of educational intervention based on the theory of planned behavior on the seat belt use behavior of rural adolescent students. J Educ Community Health. 2025; 12(3):151-155. doi:10.34172/jech.3611

Introduction

According to the Iranian Legal Medicine Organization, road traffic-related injuries (RTIs) led to 20,045 deaths and 391,069 injuries in 2023. Moreover, between 2004 and 2019, the number of fatalities due to road traffic accidents increased in rural areas of Iran (1).

Although the mean number of traffic-related crashes is usually higher in urban areas, a much greater proportion of rural traffic-related crashes result in death (2). Per 100 million vehicle miles traveled, the traffic-related death rate on rural roads (1.84) is 2.6 times higher than that on urban roads (0.71) (3).

Beck et al demonstrated that seat belt use is lower in rural areas (4). A review study indicated that not fastening a seat belt is a risk factor for road traffic injury-related mortality in Iran (5). According to the study by Tavakoli Kashani et al, seat belt use on rural roads was one of the most important factors influencing the severity of injuries in traffic crashes (6).

Demographic characteristics, including age, gender, and educational level, may influence safety belt use (7). However, Şimşekoğlu and Lajunen found that gender and age did not have a significant influence on seat belt use behavior (8). Positive attitudes and beliefs toward seat belt use can enhance the likelihood of wearing a seat belt (8,9). Watson and Austin reported that rural drivers tend to exhibit less favorable attitudes and beliefs about seat belt use than urban drivers, highlighting the need for interventions designed to address and improve these unfavorable attitudes and opinions held by rural drivers (10).

The theory of planned behavior (TPB) is a well-established framework for predicting traffic safety-related behaviors. Its constructs include perceived behavioral control, attitude, intention, subjective norms, and behavior. Intention is the strongest predictor of behavior that is shaped by attitude, subjective norms, and perceived behavioral control. Behavior itself is influenced by both intention and perceived behavioral control (11).TPB has been shown to be a suitable theory for predicting seat belt use behavior (12,13).

Seat belt usage rates are relatively low in rural communities, and the proportion of rural traffic-related crashes resulting in death is greater than in urban areas. It is necessary to improve seat belt use in rural communities. Increasing awareness of adolescent students is especially important for promoting seat belt use behavior. Educational intervention can improve adolescents’ beliefs and attitudes about seat belt use, especially in rural regions. Accordingly, this study aimed to assess the impact of an educational intervention on the seat belt use behavior of rural adolescent students.

Materials and Methods

Participants

This randomized controlled trial study was conducted in 2024 among 246 randomly selected female and male junior high school students (grades 7, 8, and 9) from rural areas of Hashtrood, East Azerbaijan Province, Iran. A total of 123 students were assigned to the experimental group and 123 to the control group. All selected students were randomly assigned to two groups: experimental (n = 4 schools) and control (n = 4 schools).

Entrance criteria were as follows: female and male students in junior high schools in grades 7, 8, and 9, residency in rural areas, willingness to participate in the study, and provision of parental consent. Exclusion criteria were the unwillingness of students or parents to participate in the study, absence from training sessions, and failure to complete the post-test.

During the follow-up period, 16 students were lost, and data were collected from 230 students (122 in the control group and 108 in the experiment group). Non-participation in educational intervention sessions and incomplete questionnaires were the main reasons for the drop in sample size.

Data Collection

The data collection tool was a questionnaire on seat belt use behavior, designed based on TPB in our previous study (14). The content validity index (CVI) and content validity ratio (CVR) of the questionnaire were above 0.90 and 0.80, respectively. Cronbach’s alpha values were ≥ 0.70.

The questionnaire consisted of two sections. The first section included demographic information such as age, students’ educational grades. The second part was designed according to the constructs of the TPB, with items addressing subjective norms, attitude, perceived behavioral control, behavioral intention, and seat belt use behavior.

• Attitude towards seat belt use behavior contains two dimensions: behavioral beliefs with seven items (e.g., “Wearing a seat belt protects my health.”) and evaluation of behavioral consequences with seven items (e.g., “It is important to me to protect my health by wearing a seat belt”).

• Subjective norms toward seat belt use contain two dimensions: normative beliefs with eight items (e.g., “My father highlights that I should wear my seat belt every time I get in the car.”) and motivation to comply with eight items (e.g., “My father highlights that fastening a seat belt is important to me”).

• Perceived behavior control contains two dimensions: control beliefs with nine items (e.g., “Restricting movement in the car when wearing a seat belt causes me not to wear it.”) and perceived power with nine items (e.g., “Restricting movement causes me not to use a seat belt when I get in a car”).

• Behavioral intentions were measured with six items (e.g., “I am going to wear a seat belt when riding in the car as a rear-seat occupant inside the city”).

• Behavior also includes six items (e.g., “I wear my seat belt when I sit in the rear seat of the car inside the city”).

For constructs of subjective norms, attitude, subjective norms, and perceived behavioral control, a 5-point Likert scale was used, ranging from 5 (completely agree) to 1 (completely disagree). For behavioral intention and behavior constructs, a 5-point Likert scale was used, ranging from 5 (always) to 1 (never).

The Intervention

An educational intervention was administered to the experimental group. The contents of the program included lectures, booklets, pamphlets, posters, educational video clips for students, a competition for creating wall newspapers and cartoons, awarding prizes to the top participants, and a pamphlet for parents. The intervention was delivered over four weeks in four 45-minute training sessions. At baseline (pre-intervention) and again three months after the intervention (post-test), students in both the intervention (pre- and post-test) and control groups completed the questionnaires using a self-reported method.

Statistical Analysis

Data were analyzed using SPSS software (version 16). Paired t-tests were used to compare the mean scores of TPB constructs before and after the intervention, and ANCOVA was applied to compare post-test scores between groups. The significant differences were set at P < 0.05.

Results

Results of the study showed that the mean ± SD of age of control and experimental groups was 14.04 ± 0.84 and 13.86 ± 0.75, respectively. There was no statistically significant difference in age between the groups (P = 0.107).

Before the intervention, the mean scores of all TPB constructs were similar in the control and intervention groups, with no significant differences (P > 0.05). In the control group, the mean score of all constructs of TPB did not differ significantly between baseline and three months later (P > 0.05).

In contrast, in the intervention group, there were significant improvements in all TPB constructs from baseline to three months after the intervention (P < 0.01). The educational intervention significantly improved all TPB constructs of seat belt use. The mean behavior score in the intervention group increased from 20.39 ± 7.37 before the intervention to 23.08 ± 6.40 at three-month follow-up, which was statistically significant (P < 0.01) (Table 1).

As shown in Table 2, ANCOVA analysis revealed that, after adjusting for baseline differences in subjective norms, attitude, perceived behavioral control, behavioral intention, and behavior between the intervention and control groups, there were significant differences in post-intervention scores between the two groups (P < 0.01). The educational intervention significantly increased the mean scores of all TPB constructs in the intervention compared to the control group (P < 0.01).

Effect size was assessed using partial eta squared coefficients, which measure the proportion of variance in the dependent variable attributable to a given factor, similar to R². Partial eta squared values are categorized as small (0.01), medium (0.06), and large ( ≥ 0.14) (15). Based on Table 2, the partial eta squared effect sizes for all TPB constructs were in the medium range.

Discussion

Although the mean number of traffic-related crashes is usually higher in urban areas, a much greater proportion of rural traffic-related crashes result in death (2). A review study reported that the pooled prevalence of wearing a seat belt was 43.94% among drivers, 38.47% among front-seat passengers, and only 15.32% among rear-seat passengers (16).

The results of the present study showed that the educational intervention improved attitude, subjective norms, perceived behavioral control, behavioral intention, and seat belt use behavior among rural adolescent students. Specifically, the mean behavior score in the intervention group increased from 20.39 ± 7.37 before the intervention to 23.08 ± 6.40 after the intervention. Previous studies have similarly reported that educational interventions can improve traffic safety-related behaviors among students (17-19).

Burkett et al implemented the Drive Alive Pilot Program (DAPP) to improve seat belt use among rural high school students. The DAPP model, derived from the Theory of Reasoned Action, Social Cognitive Theory, and Fuzzy-trace Theory, was implemented through four steps: 1) high visibility surveys, 2) incentives, 3) disincentives (enforcement), and 4) programmatic interventions (education/media). The results indicated that DAPP was effective in enhancing seat belt use among rural high school teenagers (20).

In a recent review, Lourens et al reported that behavioral education‐based interventions may promote seat belt use behavior (21). An educational intervention program in Mexico on road safety among children and teenagers demonstrated significant improvements in participants’ knowledge, practices, and attitudes about road safety after the educational intervention. The programs also improved perceptions of risk in behaviors such as traveling on overcrowded public transportation, not wearing seat belts in cars, and not using helmets on motorcycles, crossing the street while playing with friends or using mobile phones, and riding with intoxicated drivers (22).

DiMaggio and Li demonstrated that the Safe Routes to School program decreased pedestrian injuries among school-aged children (5-19 years old) (23). Houston et al reported that an educational intervention through a traffic safety campaign increased seat belt use among teen students and concluded that social pressure and poor perception of injury risk were major barriers to seat belt use among teenage high school students (24). The major limitation of the present study was the use of a self-reported method for data collection.

Conclusion

The results indicated that educational intervention programs effectively improved attitude, subjective norms, perceived behavioral control, behavioral intention, and seat belt use behavior among rural adolescent students. These findings highlight the importance of implementing educational interventions to promote seat belt use in this population.

Acknowledgments

This study was financially supported by the Road Traffic Injury Research Center, Tabriz University of Medical Sciences, Tabriz, Iran [Grant Ref. No. 72426]. The authors gratefully acknowledge this financial support.

Competing Interests

The authors declare no conflict of interests.

Ethical Approval

The present study was approved by the Ethics Committee of Tabriz University of Medical Sciences (IR.TBZMED.REC.1401.940) and conducted according to ethical norms and guidelines.

Funding

This study was funded by the Road Traffic Injury Research Center, Tabriz University of Medical Sciences, Tabriz, Iran [Grant Ref. No. 72426].

References

1. Iranian Legal Medicine Organization. Report of Road Traffic Related Death Statistics in Iran, 2023. 2023. Available from: https://www.lmo.ir/fa/page/105849%D8%A7%D8%B7%EF%BB%BC%D8%B9%D8%A7%D8%AA%D8%A2%D9%85%D8%A7%D8%B1%DB%8C.html.
2. Zwerling C, Peek-Asa C, Whitten PS, Choi SW, Sprince NL, Jones MP. Fatal motor vehicle crashes in rural and urban areas: decomposing rates into contributing factors. Inj Prev 2005; 11(1):24-8. doi: 10.1136/ip.2004.005959 [Crossref] [ Google Scholar]
3. National Highway Traffic Safety Administration (NHTSA). Traffic Safety Facts 2015 Data: Rural/Urban Comparison of Traffic Fatalities. Washington, DC: NHTSA; 2017.
4. Beck LF, Downs J, Stevens MR, Sauber-Schatz EK. Rural and urban differences in passenger-vehicle-occupant deaths and seat belt use among adults - United States, 2014. MMWR Surveill Summ 2017; 66(17):1-13. doi: 10.15585/mmwr.ss6617a1 [Crossref] [ Google Scholar]
5. Yousefifard M, Toloui A, Ahmadzadeh K, Gubari MI, Madani Neishaboori A, Amraei F. Risk factors for road traffic injury-related mortality in Iran; a systematic review and meta-analysis. Arch Acad Emerg Med 2021; 9(1):e61. doi: 10.22037/aaem.v9i1.1329 [Crossref] [ Google Scholar]
6. Tavakoli Kashani A, Shariat-Mohaymany A, Ranjbari A. Analysis of factors associated with traffic injury severity on rural roads in Iran. J Inj Violence Res 2012; 4(1):36-41. doi: 10.5249/jivr.v4i1.67 [Crossref] [ Google Scholar]
7. Rezapur-Shahkolai F, Malekpour F, Tapak L, Moeini B, Sadeghi-Bazargani H. Seat belt use behavior among teen students: the role of their demographic characteristics and family members’ behaviors. Arch Trauma Res 2021; 10(3):165-72. doi: 10.4103/atr.atr_61_21 [Crossref] [ Google Scholar]
8. Şimşekoğlu Ö, Lajunen T. Social psychology of seat belt use: a comparison of theory of planned behavior and health belief model. Transp Res Part F Traffic Psychol Behav 2008; 11(3):181-91. doi: 10.1016/j.trf.2007.10.001 [Crossref] [ Google Scholar]
9. Beck LF, Kresnow MJ, Bergen G. Belief about seat belt use and seat belt wearing behavior among front and rear seat passengers in the United States. J Safety Res 2019; 68:81-8. doi: 10.1016/j.jsr.2018.12.007 [Crossref] [ Google Scholar]
10. Watson CE, Austin RA. Differences in rural and urban drivers’ attitudes and beliefs about seat belts. Accid Anal Prev 2021; 151:105976. doi: 10.1016/j.aap.2021.105976 [Crossref] [ Google Scholar]
11. Ajzen I. The theory of planned behavior: frequently asked questions. Hum Behav Emerg Technol 2020; 2(4):314-24. doi: 10.1002/hbe2.195 [Crossref] [ Google Scholar]
12. Bener A, Ozkan T, Lajunen T. The driver behaviour questionnaire in Arab Gulf countries: Qatar and United Arab Emirates. Accid Anal Prev 2008; 40(4):1411-7. doi: 10.1016/j.aap.2008.03.003 [Crossref] [ Google Scholar]
13. Okyere P, Agyei-Baffour P, Harris MJ, Mock C, Donkor P, Yankson IK. Predictors of seat-belt use among bus passengers in Ghana: an application of the theory of planned behaviour and health belief model. J Community Health 2021; 46(5):992-9. doi: 10.1007/s10900-021-00980-7 [Crossref] [ Google Scholar]
14. Malekpour F, Moeini B, Tapak L, Sadeghi-Bazargani H, Rezapur-Shahkolai F. Prediction of seat belt use behavior among adolescents based on the theory of planned behavior. J Res Health Sci 2021; 21(4):e00536. doi: 10.34172/jrhs.2021.71 [Crossref] [ Google Scholar]
15. Gray CD, Kinnear PR. IBM SPSS Statistics 19 Made Simple. Psychology Press; 2012.
16. Kargar S, Ansari-Moghaddam A, Ansari H. The prevalence of seat belt use among drivers and passengers: a systematic review and meta-analysis. J Egypt Public Health Assoc 2023; 98(1):14. doi: 10.1186/s42506-023-00139-3 [Crossref] [ Google Scholar]
17. Borhani M, Behdad E, Mehri A, Hosseini ZS, Tatari M. The effect of an educational intervention based on the theory of protection motivation on the promotion of safe traffic behaviors in adolescents. J Educ Community Health 2023; 10(1):28-34. doi: 10.34172/jech.2023.1905 [Crossref] [ Google Scholar]
18. Mehri A, Hosseini ZS, Davarzani A, Barati H, Joveini H, Shahrabadi R. The role of education in promoting safe motorcycle riding behaviors among Iranian students: an application of the protection motivation theory and the information-motivation-behavioral skills model. J Educ Community Health 2022; 9(3):176-83. doi: 10.34172/jech.2022.26 [Crossref] [ Google Scholar]
19. Omidi S, Farmanbar R, Mokhtarpour S. The effect of educational intervention based on PRECEDE-PROCEED model on promoting traffic safety behaviors in primary schools students of Tabriz in 2014. J Educ Community Health 2016; 2(4):48-56. doi: 10.21859/jech-02047 [Crossref] [ Google Scholar]
20. Burkett KM, Davidson S, Cotton C, Barlament J, Loftin L, Stephens J. Drive alive: teen seat belt survey program. West J Emerg Med 2010; 11(3):279-82. [ Google Scholar]
21. Lourens A, Sinclair M, Willems B, Young T. Education, incentive, and engineering-based interventions to promote the use of seat belts. Cochrane Database Syst Rev 2024; 1(1):CD011218. doi: 10.1002/14651858.CD011218.pub2 [Crossref] [ Google Scholar]
22. Treviño-Siller S, Pacheco-Magaña LE, Bonilla-Fernández P, Rueda-Neria C, Arenas-Monreal L. An educational intervention in road safety among children and teenagers in Mexico. Traffic Inj Prev 2017; 18(2):164-70. doi: 10.1080/15389588.2016.1224344 [Crossref] [ Google Scholar]
23. DiMaggio C, Li G. Effectiveness of a safe routes to school program in preventing school-aged pedestrian injury. Pediatrics 2013; 131(2):290-6. doi: 10.1542/peds.2012-2182 [Crossref] [ Google Scholar]
24. Houston M, Cassabaum V, Matzick S, Rapstine T, Terry S, Uribe P. Teen traffic safety campaign: competition is the key. J Trauma 2010; 68(3):511-4. doi: 10.1097/TA.0b013e3181cc8c96 [Crossref] [ Google Scholar]