“Where Have I Heard It?” Assessing the Recall of Traffic Safety Campaigns in the Dominican Republic

Although traffic crashes are the eighth leading cause of death in the world, and are linked to vehicle and infrastructure-related factors, crash-related fatality rates are much higher in lowincome countries. Particularly, the Dominican Republic is the country with the highest accident rate in the whole American continent. Therefore, in the past few years, public agencies have been developing different measures aimed at reducing traffic fatalities, including road safety campaigns. The aim of the present study was to assess the recalling of such campaigns among the Dominican population, which may serve as an additional indicator to evaluate their effectiveness in this and other countries of the region presenting similar traffic safety issues. For this cross-sectional study, a nationwide sample composed of 1260 people (50% males and 50% females) with a mean age of 39.3 years was used. The data were collected through personal interviews. Overall, the recall of traffic safety campaigns was found to be very low (9%); male drivers who were employed, possessed a driver’s license and habitually drove were the ones who could commonly remember these campaigns. The results of this study suggest that further evaluation and follow-up could help to maximize the impact of future traffic campaigns and advertisements in the Dominican Republic, as well as in other emerging countries of the region with similar characteristics. Further, key segments of the population such as the female, young, less formally educated and non-driving populations should be also targeted for further actions in this regard.


Introduction
Traffic crashes represent a problem with a high economic, social and health-related impact on the population [1]. The latest data recorded by World Health Organization indicate that traffic accidents are the eighth leading cause of death worldwide, explaining almost 1.4 million fatalities yearly [2].
This situation is even more serious in emerging countries, if several existing shortcomings and gaps are considered. In brief, low-and middle-income countries (LMICs) are characterized by having an average low per capita income and a very limited advancement in their development and infrastructure and human development. Even so, economic growth, industrialization, and exportation have been rising with globalization dynamics, often implying unexpected (or unplanned) problems for key sectors such as transportation [3]. Colombia, Peru, Ecuador and the Dominican Republic are some noteworthy examples [4]. Emerging countries have a traffic accident death rate of 29.4 per 100,000 inhabitants compared to the world rate of 18.8 per 100,000 inhabitants [5].
For the past few years, the Dominican Republic has been the country with the highest number of fatal victims in traffic accidents. The death rate of traffic accidents fluctuates, but it has been stable at over 20 for every 100,000 inhabitants since 2008 [6]. These data make the Dominican Republic the country with the highest death rate from traffic accidents in the whole American continent [5].
Deaths related to traffic accidents are the second leading cause of external or violent death in the Dominican Republic. Thus, the data from the Permanent Observatory of Road Safety (Observatorio Permanente de Seguridad Vial-OPSEVI) have shown that the number of casualties caused by traffic accidents was 3204 in 2019 (the latest available data), with men between 15 and 29 years old as the population group with the highest rate [7].
In the past few years, from the National Institute of Traffic and Land Transportation (INTRANT, Domincan Republic), a set of measures have been developed, addressing the awareness of the population and the reduction in traffic crash rates in the country. Thus, new laws and norms have been approved within this scope, and actions have been carried out to improve the public infrastructure and the conditions of public transportation, emphasizing the road education of citizens [8].
In this sense, communications campaigns are very relevant since they are an appropriate way of transmitting changes happening in the traffic and road safety field to the Dominican Republic population [9]. Without appropriate use of the media and advertising campaigns, it will be difficult to achieve a real change in the attitudes and behaviors of road users [10,11]. For this reason, the communication plans of the traffic sector throughout the whole world tend to produce advertisements with a high emotional impact, using fear as their persuasive element [12] in addition to using messages or slogans that, with their repetition through different media, manage to be remembered by users.
In the Dominican Republic, different communication campaigns were developed in the years 2018 and 2019, aimed at both at-risk groups (pedestrians, cyclists, motorcyclists, etc.) and to the population as a whole. This is the case of "safe pedestrian action", "I use the bike", or "don't drive if you drank" [13]. The purpose of the traffic campaigns is to raise public awareness of road safety risk factors in order to reduce accidents and improve mobility, which will have a direct impact on reducing pollution and energy consumption [14].
Communication campaigns have been shown to have a certain level of effectiveness. It is difficult to isolate the impact of advertisements, as they are usually broadcast in conjunction with the implementation of other preventive measures [15]. However, previous research shows that campaign effectiveness significantly increases when they are used to complement regulations and sanctions [16,17]. Therefore, it is essential to make ads with appropriate features so that users remember the message and apply it in their journeys.
However, as has been previously mentioned, carrying out a campaign does not necessarily imply that the population will perceive and incorporate all the information that needs to be transmitted. Although recall is not the only important element in raising awareness among the population, it is a necessary first step in the process of acquiring appropriate road behavior. Therefore, the objective of this research is to find out to what extent the inhabitants of the Dominican Republic remember the communication and advertisement campaigns related to traffic, mobility, and road safety that have been carried out in recent years. Likewise, we will analyze whether there are population groups that are especially inclined to remember such advertisements, with the aim of improving the efficacy of future campaigns in the country.
After reviewing the literature and stating the objective of the study, the materials and methods used will be presented. Subsequently, the obtained results will be developed, and the data will be contrasted with other studies in this thematic area in the discussion. Finally, the most relevant conclusions will be presented.

Participants
The sample was composed of 1260 adult inhabitants of the Dominican Republic. The sample distribution was proportional to the population, according to the ONE census (National Statistical Office), by age (M = 39.3; SD = 15.37), gender, habitat and province [18] (Table 1). To obtain the necessary representativeness, the minimum sample size should be about n = 680 if we assume a level of confidence of 99%, a maximum margin of error of 5% (α = 0.05) and a beta β) of 0.20, which allows for an 80% power (Table 1). Participation was voluntary and anonymous. The personal information management was carried out in accordance with the current laws on data protection, complying with ethical requirements.

Design, Procedure and Instruments
The data reported in this study were collected through the National Survey on Mobility of the Dominican Republic from the year 2019 [19]. The questionnaire included issues related to the knowledge of institutions and traffic laws, public transportation, private transportation, on-foot movements, bike use, ITS systems and measures, among which the variables of the present research are included. It is a pioneer questionnaire in Latin America, where such exhaustive and complete instruments have not been administered. It began to be administered in 2018 to assess the situation in the country and detect the evolution and changes in the way Dominicans move as a result of the implementation of the various initiatives carried out by INTRANT.
The survey was administered through personal, in-person interviews with a duration of approximately 20 min. The sample was obtained during a time span from 24 November to 7 December 2019. The gathering of information was carried out through a CAPI system (Computer Assisted Personal Interviews) on tablets, recording and geo-referencing the interviews, with the aim of expediting the duration of the interview and minimize any recording mistakes.
In order to achieve the proposed objectives, the following variables were taken into account:

Data Processing
For this study, descriptive (frequency) analyses were carried out with the aim of describing and characterizing the general remembrance of traffic campaigns among the Dominican population. Moreover, Chi-square (χ 2 ) analyses were performed in order to obtain possible statistical associations with sociodemographic variables. Subsequently, and after basic statistical parameters were tested and met, a binary logistic regression (i.e., Logit) model was designed, using the fact of having recalled at least a traffic safety campaign as a dependent and binomial variable, where 1 = Yes and 0 = No, using basic demographic variables whose coverage is common to the whole population. Statistical analyses were carried out using the ©IBM SPSS (Statistical Package for Social Sciences) version 26.0 (Armonk, NY, USA).

Ethics
This type of study does not require ethical approval. No personal data were used, and the participation was anonymous, implying no potential risks for the integrity of our participants. However, the "Ethics Committee of Research in Social Sciences in Health" from the University Institute on Traffic and Road Safety of the University of Valencia (Spain) was consulted, certifying that the research responds to the general ethical principles relevant to research in Social Sciences. The Committee expressed its approval for the research. All participants gave their consent before taking part in the study and after receiving an explanation of its objectives, as well as all the previously mentioned considerations, from the research staff.

Results
The recall of these traffic safety-related communication campaigns or messages on traffic safety awareness in the Dominican Republic can be considered, at first glance, as very low, as only 9% of the sample answered positively to the corresponding question ( Figure 1). More than half of the participants had seen the campaigns on TV (62.8%), and they had been produced by different organizations, among which the INTRANT stands out (35.4%).
Concerning the topic of the campaigns, there are not any that stand out. In Table 2, it can be observed that the use of seatbelts, safety and mobility, the don't drive if you drank campaign, and respect the laws are the most repeated elements, despite showing only a small difference from the rest. Moreover, it is remarkable that 21.2% of participants do not remember what the advertisement was about.
After analyzing the data depending on the different sociodemographic characteristics, we found that the only cases in which significant differences are produced are gender and job situation. Men and people who are currently employed are the ones who remember traffic campaigns the most (Table 3). Concerning the data related to driving, it is observable how people who drive any motor vehicle are those who remember this type of campaign the most. In relation to this, there is also a significant difference in the habitual driving and driver's license variables. On the other hand, no differences appear depending on the type of license, and neither on the type of driver (professional or private) ( Table 3).  Concerning the topic of the campaigns, there are not any that stand out. In Table 2, it can be observed that the use of seatbelts, safety and mobility, the don't drive if you drank campaign, and respect the laws are the most repeated elements, despite showing only a small difference from the rest. Moreover, it is remarkable that 21.2% of participants do not remember what the advertisement was about.   If we focus on the media that were issuing the advertisement or campaign, it is interesting how the only sociodemographic variable reflecting significant results is age (Chi2(24) = 39.252; p = 0.026). In Table 4, we can observe that, despite television being the media from which all groups remember most campaigns, it comes out as especially remarkable for young people between 25 and 34 and people between 50 and 64. Likewise, people between 35 and 49 have had more access to campaigns through the press and the internet than the rest of groups. A binary logistic regression analysis was carried out taking into account the independent variables: sex, age, habitat, educational level and driving status (being or not a driver). This significant model, conducted through a binomial logistic regression technique, was fitted using both demographic and road safety and demographic variables. The function defining the binary logistic regression model is presented below: P(Y = 1; X i ) = e zi /1 + e zi where z i = β 0 + β 1 X 1 + β 2 X 2 + · · · β 10 X 10 + ε The variables included in the model were defined as: Y i = 1, which implies having recalled at least one traffic safety campaign performed in the country.
Y i = 0, which implies not remembering any traffic safety campaign performed. X 1 , X 2 , . . . X n : Independent (whether continuous or categorical-dummy) variables included in the model, where Sex (X 1 ; dummy variable), Age (X 2 ) and Educational level (X 3 ) represent the three independent variables of the model, as shown in Table 5. The final solution presented an overall accuracy percentage of 91.0%, explained 19.1% of the variance among subjects (Nagelkerke's R 2 = 0.191) and showed a − 2Log-likelihood coefficient of 690.412. The basic parameters and variables included in the model are presented in Table 5, showing its Beta coefficients, significance level and odds ratio (OR). Three of the study variables had significant results ( Table 5), indicating that sex (i.e., the fact of being a man), a greater age and educational level are significant predictors of the fact of remembering at least one of the road safety communication campaigns previously conducted in the Dominican Republic. The greatest Wald (χ 2 ), that is, the individual test statistic for each predictor variable, corresponded to the variable "Educational level" (Wald = 56.698), which has shown to be the most relevant demographic predictor among those included in the significant model.

Discussion
The core aim of this study was to assess to what extent inhabitants of the Dominican Republic remember traffic safety campaigns. In general terms, the results reflect a very low recall of advertisement campaigns in the scope of traffic, mobility and road safety, even below the data obtained in previous years (in 2018, the rate of remembrance was 11.2%) [20]. This implies a huge issue for the country, since it indicates that, at the moment, the population is not aware of traffic accidents being the second leading cause of violent death in the Dominican Republic, when citizens are actually essential to reverse the situation [7].
Thus, although in recent years, multiple communication campaigns have been carried out within the traffic and road safety sector in the Dominican Republic, the recall of these campaigns remains low. In Table 6, the main campaigns carried out during 2019 in the country, most of them broadcasted by different media, are shown. [21,22]. In this sense, it is convenient to remark that there is only one campaign that is remembered for its slogan. This is Don't drive if you drank, which refers to alcohol consumption when driving [22]. It is a message that was heavily emphasized during the year before the survey, and, in a way, it is positive that this slogan is one of the most remembered elements. In this sense, it would be useful to reflect on which variables are present in this campaign (and not in other ones) so that this situation may be reproduced.
The Don't drive if you drank campaign was broadcasted by different media, such as television, radio, newspapers, digital press and social networks. Likewise, there were acts and events related to this campaign in universities, where there was an attempt to raise young people's awareness of the detriments of alcohol consumption while driving (INTRANT, 2020b). This is important since it indicates that the message was strengthened enough for the majority of the population to access it, and therefore achieves an adequate spread, both of which are essential aspects of social marketing [23,24].
However, it must be distinguished between the recall of a campaign and its actual effectiveness. Biases can be generated and distort the recall of the advertisement, causing the message to be different from the one internalized by the users [25]. In this sense, it would be interesting to go deeper into further research on other elements that influence the effectiveness of a campaign, beyond recall, such as the change in attitudes and behaviors and the impact of the increase of knowledge on the viewer [26]. Therefore, the monitoring and evaluation of campaigns are also fundamental, being particularly important in the early years of the evolution of media campaigns in low-and middle-income countries [27].
The advertisements related to this campaign do not present especially violent images; they rather inform by providing a clear message. Maybe a higher impact could have been achieved had they used a more emotional component [28], as happens in other countries with similar campaigns, such as Spain [29] or Mexico [30]. In Spain, the highest peak of deaths caused by traffic accidents occurred at the end of the 1980s. At this time, the Dirección General de Tráfico (DGT) changed its approach to communication campaigns, starting to make advertisements with much more raw images, showing in a realistic way the terrible consequences that can result from irresponsible driving behavior. This contributed to the reduction in the accident rate that occurred during the 1990s in this country [12]. However, the communication strategy was changed in the following years because the prolonged high impact levels substantially reduced the effectiveness of the campaigns [31]. These results are repeated in advertisements that promote healthy behaviors beyond the transit sector (e.g., tobacco or safe sex), where it has been shown that high-impact campaigns could attract the viewer's attention but prevent learning and retention of public health problems [32]. For this reason, several studies indicate that the most appropriate formula is to intersperse campaigns with low and high visual impact so as not to habituate the user [33]. It is important to take as a reference the strategies and advertisements made in other countries because campaign messages that have proven to be effective in one environment can also be tested in other contexts (with prior adaptation), which could save resources and time [27].
On the other hand, the use of social networks is necessary because it makes the problem feel closer to the population, especially to young people, the group that uses them the most [34]. It is surprising that, according to the present research, young Dominicans do not have more memories of campaigns seen on social media. This can indicate that the way of conveying the information was not adequate or that the INTRANT social networks do not have enough engagement yet to influence the thoughts and behaviors of their followers [35]. Therefore, it is necessary to establish a good relationship with users through an accessible social network that will allow interaction with followers, with frequent publications, relevant and interesting information for Dominicans, encouraging users' participation, answering their questions and paying attention to their suggestions. These easy strategies can turn the INTRANT profile into a better communication source, with a more significant impact on the population and a very low economic cost [36].
However, this is a process that can take time. Therefore, future campaigns in the Dominican Republic must focus on television, since it is clearly the medium from which campaigns are remembered the most. This is interesting, since it is consistent with what happens in many countries around the world, where the television is still the preferred medium for advertising [37]. Thus, according to a study conducted by Nielsen IBOPE, in the Dominican Republic, open TV channels in 2019 reached more than 99.24% of all people in Santo Domingo and the province of Santiago. Viewers' consumption time increased to 115 min per day, consolidating television as the medium with the greatest impact and reach in the country. Largely because of this, 67% of the advertising investment in 2019 was made in this medium [38]. Regarding age groups, children (4-11 years) reached 15%, adolescents (12-17) 9.6%, young adults (18-34) 22%, adults (35-54) 30% and seniors over 55 years 23% [38]. Similar data are obtained in other emerging countries. In Latin America, television is widely consumed by the population as a whole, although more and more people opt for on-demand services, especially young people [39].
In this sense, despite the rise of social networks, this type of media is only useful for supporting the main advertisements issued on television, and this does not even apply to every case [40,41]. Thus, in future campaigns, the Dominican Republic could follow up with this strategy, issuing most information through television and using the rest of the media as a complement for establishing the new ideas and behaviors in the population.
Another expected element that should be remarked on is that the most influential variable in the recall of traffic campaigns is being a driver. All variables where a significant difference appeared between groups share this unifying element: driving a motor vehicle, being a habitual driver, and having a driver's license. Even in the case of the gender and job situation variables this link has been found, since those who drive the most in the Dominican Republic are men and people who have a job. This phenomenon can be explained because drivers may have more interest to pay attention to traffic advertisements in comparison with non-drivers. This is a key element in the attention to and retention of information [42,43].
Such circumstances may be useful for future campaigns, as it is drivers who cause most traffic accidents due to human error [44,45]. However, it should not be forgotten that pedestrians and motorists are the most vulnerable groups, being those who die the most from a traffic accident. Thus, the subject matter of the spots should be especially aimed at drivers, warning of the importance of the human factor, with special emphasis on distractions, alcohol and drug consumption and speeding due to their significant influence on accident rates [46,47].
In addition, emphasis should be placed on motorcyclists since, in the Dominican Republic, motorcycles represent more than 55% of the country's vehicle fleet [48]. This situation also occurs in many of the emerging countries of Latin America, especially because of motorcycle cabs (or moto-taxis), which are motorcycles that act as public transport twowheeled vehicles for the movement of travelers [49]. These vehicles are involved in a high number of traffic accidents, and may be influencing variables such as drowsiness, fatigue and high workload [50]. Therefore, it would be relevant to act specifically on this risk group in future campaigns carried out in these countries.

Conclusions
The improvement of road safety and mobility in the Dominican Republic is necessary because of the high accident rates and deaths that have been happening in the country in recent decades [51]. The first step for users to remember the communication campaigns that are being carried out in the Dominican Republic is to increase their awareness of road safety and their appropriate behaviors on the road. This research establishes that the recall of the campaigns is very low. Hence, a change in the design and elaboration of the advertisements in this sector is necessary.
Thus, given the circumstances, the elaboration of future campaigns in the Dominican Republic might require extensive further evaluation and follow-up, a fact that could help to maximize the impact of future traffic campaigns and advertisements in the Dominican Republic, as well as in other emerging countries of the region with similar characteristics. Further, this study found that not all population segments in terms of sex, education and income have the same remembrance level, and gaps in terms of access to information channels and sources may possibly be enhancing it. In this regard, key segments of the population, such as the female, young, with lesser educational levels and non-driving population, that have been found as benefiting less from them should also be targeted for further campaigns and communicative strategies aimed at strengthening traffic safety.
Author Contributions: For this study, F.A. and M.F. conceived and designed the research and performed the data collection; S.A.U. supervised data collection and coding; S.A.U. and M.F. analyzed the data; C.F. and S.A.U. contributed with reagents/materials/analysis tools; M.F. and S.A.U. wrote and revised the paper. All authors have read and agreed to the published version of the manuscript. Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.

Data Availability Statement:
The data will be available upon reasonable request to the corresponding author.