1 
2 
Final Evaluation and Scaling 
Report 
Head Safe. Helmet On. 
Grant No. AID-OAA-F-14-00012 
September 2016 
 
AIP Foundation 
12B Ngoc Khanh, Ngoc Khanh Ward 
Ba Dinh District, Hanoi, Vietnam, 1148457 
(84-8) 3771 0700 Fax (84-8) 3771 0701 
www.aip-foundation.org
Disclaimer 
This report is made possible by the generous support of the American People. The contents of this 
report are the sole responsibility of the AIP Foundation and do not necessarily reflect the views of the 
United States Agency for International Development or the United States Government.
3 
Table of Contents 
Table of Contents .................................................................................................................................... 3
Table of Tables ........................................................................................................................................ 4
Table of Figures ....................................................................................................................................... 4
Acronyms ................................................................................................................................................ 4
Executive Summary ................................................................................................................................. 5
Background ......................................................................................................................................... 7
Overview of “Head Safe. Helmet On.” (HSHO) ...................................................................................... 7
Program Design & Implementation.......................................................................................................... 7
Goals and Targets ................................................................................................................................ 7
Implementation ................................................................................................................................... 8
School-Based Program (SBP) ............................................................................................................ 8
Behavior Change Communications (BCC) ......................................................................................... 8
Enabling Environment Change (EEC) ................................................................................................ 9
Stakeholder Engagement ..................................................................................................................... 9
Beneficiaries ...................................................................................................................................... 10
Challenges During Implementation .................................................................................................... 12
Evaluation Design .................................................................................................................................. 13
Impact Evaluation Design .................................................................................................................. 14
Results and Findings .............................................................................................................................. 15
Short- and Medium-term Results ....................................................................................................... 15
School-Based Programs (SBP) ........................................................................................................ 15
Behavior Change Communications (BCC) ....................................................................................... 16
Enabling Environment Change (EEC) .............................................................................................. 17
Long-term Results.............................................................................................................................. 17
Closer Analysis of Results Including Lessons Learned and Next Steps ................................................. 21
Cost-effectiveness & Competitive Landscape ......................................................................................... 26
Cost-Effectiveness ............................................................................................................................. 26
Competitive Landscape ...................................................................................................................... 27
Project Improvement and Scaling Plan................................................................................................... 27
Annexes ................................................................................................................................................ 30
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Table of Tables 
Table 1: Stakeholder Matrix 
Table 2: Realized Cost Savings 
Table 3: Stakeholder Roles in Scale-Up
Table of Figures 
Figure 1: Change in Helmet Use at Schools – Control vs. Target Schools 
Figure 2: Change in Attitudes and Behaviors in Target Communes – Baseline to End-line 
Figure 3: Change in Adult Passenger Helmet Use Rates – Baseline to End-line 
Figure 4: Change in Driver Helmet Use Rates – Baseline to End-line 
Figure 5: Change in Helmet Use Rates for Child and Adult Passengers – Baseline to End-line 
Figure 6: Adult Passenger Helmet Use – National vs. Local Roads
Figure 7: Change in Road Incidents – 2015 to 2016 
Figure 8: Adult and Child Passenger Helmet Use – Control vs. Target 
Figure 9: Child Passenger Helmet Use – Control vs. Target 
Figure 10: Adult Passenger Helmet Use – Control vs. Target 
Figure 11: Driver Helmet Use – Control vs. Target
Acronyms 
AIP – Asia Injury Prevention 
BCC – Behavior Change Communications 
EEC – Enabling Environment Change 
HSHO – Head Safe. Helmet On. 
MoEYS – Ministry of Education, Youth, and Sport 
NRSC – National Road Safety Committee 
RCVIS – Road Crash Victim and Information System 
SBP – School-Based Program 
SDG – Sustainable Development Goal 
USAID-DIV – United States Agency for International Development’s Development Innovation Ventures
US CDC – United States Centers for Disease Control and Protection 
5 
Executive Summary 
This Final Evaluation and Scaling Report assesses the “Head Safe. Helmet On.” (HSHO) project in 
Cambodia, supported by the United States Agency for International Development’s Development 
Innovation Ventures (USAID-DIV) Grant No. AID-OAA-F-15-00012 to AIP Foundation. 
The project sought to increase helmet use among motorcycle passengers, thereby reducing the number 
of injuries and fatalities on the road and avoiding associated losses to Cambodia’s developing economy. 
To do so, three mutually reinforcing campaigns were implemented at both a national and local level 
with a focus on three target provinces, Phnom Penh, Kandal, and Kampong Speu: 
1. School-Based Program (SBP) increased helmet use and road safety skills at 18 target schools by 
providing quality helmets and road safety education to all students and teachers while 
reinforcing road safety messages through various interactive activities that also engaged parents 
and other stakeholders. 
2. Behavior Change Communications (BCC) raised awareness on the importance of motorcycle 
passenger helmet use, including for children, and improved related attitudes and practices 
through mass media, street-based, and commune-based campaigns. 
3. Enabling Environment Campaign (EEC) supported the passage and enforcement of 
Cambodia’s new passenger helmet law by leading strong advocacy efforts through 
continuous engagement of relevant stakeholders in meetings, workshops and study tours.
During the implementation period from June 2014 to June 2016, HSHO benefitted 226,358 people 
directly, and reached 14.04 million people indirectly. The project also realized notable achievements 
by the end of its two-year period. Cambodia passed a new road traffic law in January 2015 and 
began enforcement of the new law in January 2016 that – for the first time – required passengers, in 
addition to drivers, to wear helmets. Enforcement of the passenger helmet law for adults has 
contributed greatly to increases in adult helmet use – both adult passengers and drivers – from 
project start to end, preventing an estimated 349 casualties and saving Cambodia $3,089,316 in 
avoided losses in HSHO's three target provinces. Looking at the increase in adult passenger helmet 
wearing rates from 11.3% to 36.0% alone, an estimated 97 casualties were prevented and losses of 
$859,273 were avoided across the target provinces. On national roads where 68% of crashes occur 
in Cambodia, adult passenger helmet wearing rates were even higher by the end of the project, 
reaching 44.5% on average. Additionally, a woodwork effect was seen for motorcycle driver helmet 
rates in the three provinces, which increased from 63.0% to 75.7% over the course of the program, 
preventing 252 casualties and saving Cambodia an additional $2,230,073. Importantly, the 
nationwide enforcement of passenger helmet use suggests that these estimates are necessarily 
underestimates of the true value of the HSHO program as they only reflect increases in adult helmet 
use across the three project provinces. 
Current enforcement of the passenger helmet law does not incorporate children into the sub-decree 
on fines. Moving forward, there is an opportunity to save additional lives by incorporating this 
vulnerable group into both enforcement measures and the sub-decree on fines. However, it is 
important to note that SBP activities have been directly linked to improved outcomes for children, 
with child helmet use increasing by 74% and at least 332 children identified as being involved in a 
crash while wearing a helmet supplied by the project. 104 of those children were passengers on 
6 
motorcycles at the time of the crash. 
Based on experiences over the last two-years, a modified project has potential for larger scale-up 
supported substantially through the public sector, with some resources reallocated to maximize the 
reach and impact of the program. While SBP efforts saw substantial gains in helmet wearing rates 
amongst school children, the program was also very resource-intensive and future efforts would be 
best scaled down to select ‘model’ schools while simultaneously advocating for policy change and 
child helmet enforcement as part of EEC for nationwide scaling. BCC activities should be refocused
on achieving greater reach at the provincial, district, and national levels, shifting efforts away from 
grass-roots activities in targeted communes which did not yield significantly greater results than 
those achieved through broader campaigns.
The following Report elaborates key objectives and results of the project, as well as a review of its 
program design, implementation, and evaluation methodology. After discussing an analysis of the 
program and its outcomes, lessons learned from implementation, and overall cost-effectiveness of the 
model, the Report concludes with evidence-based justification for scaling a refined HSHO model both in 
Cambodia and abroad. 
7 
Background 
Overview of “Head Safe. Helmet On.” (HSHO) 
HSHO implementation extended from June 1st, 2014 to June 1st, 2016 in 18 target communes selected 
from three provinces: Phnom Penh, Kampong Speu, and Kandal. Elements of the project – namely mass 
media campaigns and legislative and policy advocacy – had nationwide reach. 
The three components of the project are as follows: 
1. School-Based Program (SBP) increased helmet use and road safety skills at 18 target schools by 
providing quality helmets and road safety education to all students and teachers while 
reinforcing road safety messages through various interactive activities that also engaged parents 
and other stakeholders. 
2. Behavior Change Communications (BCC) raised awareness on the importance of motorcycle 
passenger helmet use, including for children, and improved related attitudes and practices 
through mass media, street-based, and commune-based campaigns. 
3. Enabling Environment Campaign (EEC) supported the passage and enforcement of 
Cambodia’s new passenger helmet law by leading strong advocacy efforts through 
continuous engagement of relevant stakeholders in meetings, workshops and study tours.
USAID-DIV invested a total of $635,993 in the HSHO program. With cost-share from The UPS Foundation 
and FIA Foundation, investment for the project reached $1.1 million. Additional cost-share partners 
include the Road Safety Fund and the United States Centers for Disease Control and Prevention (US CDC) 
who provided in-kind support. 
Implementing Organization
AIP Foundation is a U.S. registered 501 (c)(3) non-profit organization with the mission to prevent the 
millions of unnecessary road injuries and deaths that disproportionately affect rapidly mechanizing, low￾and middle- income countries. Founded in 1999 in Vietnam, AIP Foundation has expanded its offices to 
Cambodia, China, and Thailand. Today, the organization comprises over 40 staff members with valuable 
skills and experience as road safety practitioners knowledgeable of local contexts. AIP Foundation’s 
partners are from both the public and private sector, and include the United States Agency for 
International Development’s Development Innovation Ventures, the U.S. Centers for Disease Control 
and Prevention, the FIA Foundation, Safe Kids Worldwide, Save the Children, The UPS Foundation, 
Abbott Laboratories, Chevron, Johnson & Johnson, and local government agencies. 
Program Design & Implementation 
Goals and Targets 
HSHO set an ambitious target of increasing motorcycle passenger helmet use rates in intervention areas 
from an average of 10% at the district level to 60% by the end of its two-year implementation with the 
larger goal of reducing the rate of injury and death among motorcycle passengers in Cambodia. 
The two-year project has seen substantial gains with passenger helmet use, as well as increases to driver 
helmet use that were not originally included in the targets for the project. Adult and child passenger 
8 
helmet use increased by over 20% across the three provinces, from a baseline of 10.3% to an end-line of 
33.4%, and driver helmet use increased by over 10%. Despite these substantial gains, HSHO was unable 
to meet the aggressive 60% target within the two-year time frame due in part to delays with the 
enforcement of the passenger helmet law. However, it is important to note that the project still 
achieved marked and cost-effective impact, which will be discussed in greater detail below. 
Implementation 
Implementation of HSHO took place in Cambodia at national, provincial, district, and commune levels 
over a two-year period. Key activities under each components are outlined below. 
School-Based Program (SBP) 
SBP focused its efforts on 18 schools selected from target communes in Phnom Penh, Kandal, and 
Kampong Speu provinces during the two school years that fell during the project (November 2014 –
August 2015; November 2015 to August 2016). Key activities implemented under the SBP component of 
HSHO included the following: 
 Development of road safety curriculum and organization of teacher training workshops to 
introduce effective methods for teaching road safety 
 Installation of helmet use billboards and posters 
 Helmet donations for students and teachers at large launch ceremonies 
 Organization of parent information sessions 
 Distribution of parent commitment letters asking them to pledge their support to the project 
and child helmet use as well as SBP and BCC flyers with key road safety messages 
 Implementation of tailored student activities to promote road safety for each school context 
Behavior Change Communications (BCC) 
BCC implemented both grassroots and mass media campaigns from April 2015 to May 2016 to 
compensate for the long lead time required for both designing and producing high-quality material for 
distribution and to receive feedback from key stakeholders – including endorsement from the national 
government. Select nationwide and district-level activities included the following: 
 Dissemination of press releases and public relations campaign across online, print, and social 
media platforms to reinforce key BCC messages 
 Production and airing of both television and radio commercials as well as roundtable discussions 
and talk shows 
 Installation of billboards, banners, and motorcycle taxi (tuk-tuk) panels with important road 
safety messages at the district-level 
 Organization of campaign days across all targeted districts promoting passenger helmet use 
through volunteer information sharing as well as distribution of flyers, posters, and helmet 
vouchers in the target districts 
Commune-level activities included: 
 Organization of door-to-door awareness campaigns 
 Support for commune-based working groups to conduct road safety events 
 Distribution of campaign messages through loudspeakers 
9 
Enabling Environment Change (EEC) 
The EEC component engaged with stakeholders on a regular basis, adjusting focus as needed from 
advocating for the passage of the passenger helmet law to working with government stakeholders to 
design an action plan for enforcement of the law. Due to the nature of advocacy efforts, many of the 
EEC activities were conducted at the national level including, but not limited to, the following: 
 Dissemination of policy briefs about the draft passenger helmet law 
 Organization of nationwide stakeholder workshops aimed at building the capacity of 
government stakeholders 
 Coordination and support for the development of a National Passenger Helmet Enforcement 
Action Plan implemented in January 2016 
 Organization of an enforcement study tour with members of the National Road Safety 
Committee (NRSC) 
At the local level, EEC activities mirrored those conducted at the national level in order to further build 
capacity of district and commune officials to incorporate road safety as a priority, which included the 
following: 
 Organization of district-wide stakeholder workshops and commune-wide meetings to engage 
stakeholders with the project 
 Coordination and support for the development of district passenger helmet enforcement action 
plans 
 Organization of an enforcement study tour with representatives from the traffic police 
 Organization of commune-wide meetings to share best practices and coordinate efforts 
The three components were designed to mutually reinforce one another by reaching Cambodian road 
users with important safety messages through various platforms and strategies. While SBP and BCC 
were implemented without major obstructions to the projected timeline, EEC experienced a significant 
challenge to achieving its stated objectives when enforcement of the new passenger law was delayed by 
six months from June 2015 to January 2016, as is elaborated below under the Challenges During 
Implementation section. 
Stakeholder Engagement 
Given the nature of project activities, HSHO required active involvement with government stakeholders 
across all three components. In order to effectively engage with these stakeholders, AIP Foundation 
relied heavily on pre-established working relationships with key government counterparts developed 
over years of work in Cambodia. These long-term relationships were crucial for pushing forward 
initiatives and mobilizing the necessary resources for HSHO implementation. Without these connections 
in place, there would have been additional obstacles and delays with implementing the project, and EEC 
advocacy efforts in particular would likely have been much less effective. 
The long-term presence of AIP Foundation in Cambodia and the knowledge of local staff also allowed for 
the effective navigation of the complex procedural processes inherent to working with government 
stakeholders, which often included lengthy, formal, and paper-based communication. In addition, AIP 
Foundation staff members have a well-developed knowledge of the appropriate channels for 
stakeholder communication – essential within such a hierarchical structure – that relies upon previous 
10
efforts to identify and map out stakeholder roles and capabilities as well as internal government power 
dynamics. 
Government stakeholders engaged with implementing the project include the following: 
Table 1: Stakeholder Matrix 
Stakeholder Description Type of engagement
National Road Safety 
Committee
Lead body responsible for 
coordinating road safety 
activities nation-wide; Conducts 
regular awareness campaigns 
on national television and radio; 
Oversees the Road Crash Victim 
and Information System
Government counterpart, 
national level
Department of Traffic Police 
and Public Order, National 
Police, Ministry of Interior
Responsible for traffic police 
enforcement of the traffic law
and driver education, action 
planning at the national and 
sub-national level and
awareness raising campaigns
Government counterpart, 
national, provincial, and district 
level
Ministry of Education, Youth, 
and Sport (MoEYS)
Gives endorsement for SBP, 
access to schools and in-kind 
support 
Government counterpart, 
national level
Ministry of Information Provides support for BCC mass 
media airings; Supports NRSC 
awareness raising efforts 
Government counterpart, 
national level
Provincial, district, commune 
level councils
Gives approval to local level 
road safety activities
Government counterpart, sub￾national level
Commune-level Road Safety 
Working Groups
Oversees community level road 
safety education and awareness 
raising activities 
Government counterpart, 
commune level
School management Implements and sustains 
school-based activities on a 
regular, long-term basis
Public servants counterpart, 
Commune level
Beneficiaries 
HSHO activities targeted primary school students, their parents and teachers, motorcycle passengers 
between 15 and 44 years of age, and government officials and traffic police residing or working within 
the target provinces. 
These direct beneficiaries of the HSHO project were selected for various reasons: 
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 Children currently display markedly low helmet wearing rates, with the most common reason 
being that adults do not put helmets on their child because they think they are too young.1
 As 
such, primary s chool students are particularly vulnerable road users who are also still 
developing the skills, attitudes, and behaviors necessary for staying safe as pedestrians and 
passengers now and into adulthood; 
 Parents and teachers are a respected source of road safety information for children, so 
influencing their beliefs is crucial to changing child helmet practices;2
 Road users between 15 and 44 years of age have the highest fatality rate across Cambodia;3
 and 
 Government officials and traffic police residing or working within target districts and communes 
are the key decision-makers in charge of enforcement of the passenger helmet law and set the 
standards for behavior in their communities. 
The above beneficiaries were selected from three target provinces based on a close review of road 
safety “black spots,” which are the most dangerous locations for road users. Together, the three target 
provinces – Phnom Penh, Kandal, and Kampong Speu – made up nearly one-fourth of road fatalities in 
Cambodia prior to the start of HSHO in 2013.4
 These three provinces, and Cambodia as a whole, are 
characterized by a low-income population. While Phnom Penh had a higher average family monthly 
income of 690 USD as of 2014, the average household income in Kandal and Kampong Speu was likely 
between the rural average income of 320 USD and the urban average income of 450 USD.5
 This small 
amount of money is expected to support an entire family, or 4.6 people on average.6
 
Within each province, three communes were selected from each of the two target districts for focused 
program implementation. These regions were selected based on the following criteria: 
• Crossed by at least one National Highway, given that 68% of crashes occur on National Roads; 
• High numbers of motorcycle crash injury, fatality, and casualty cases according to the most 
recently available data; 
• Potential resources to support road safety and passenger helmet use action plans; 
• Complementary road safety activities, which can support and build upon our successes; 
• Commitment, enthusiasm, and readiness on the part of district leaders to participate in road 
safety activities; and 
• Demonstrated resources and capabilities that would contribute to the sustainability of the 
project results after the conclusion of HSHO efforts. 
HSHO reached a total of 226,358 direct beneficiaries, 7 exceeding our target of 222,445: 
 SBP Program: 22,735 primary school students; 643 teachers; 36,788 parents; and 210 local 
community members in target provinces. 
 
1
 AIP Foundation (2011). Cambodia Helmet Vaccine Initiative Key Baseline Research Results. Phnom Penh, 
Cambodia.
2
 Ibid.
3 2013 Annual Report Road Crashes and Casualties in Cambodia, Road Crash and Victim Information System. 
4
 Ibid.
5
 Cambodia Socio-economic survey 2014, National Institute Statistic, Ministry of Planning. 
6 Release of Preliminary Results of 2013 Inter-censul Population Survey of the Kingdom of Cambodia. National 
Institute of Statistics, Ministry of Planning. 
7
 Includes beneficiaries from the eighteen target communes and schools, as well as nationwide. 
12
 BCC Program: 29,375 motorcycle passengers who received helmet safety literature; 124,658 
commune residents who received direct communications such as loudspeaker announcements; 
9,289 individuals who engaged directly with road safety messages through social media, radio, 
or TV at national, provincial, district, and commune levels. 
 EEC Program: 2,660 stakeholders who directly engaged in meetings or workshops at national, 
district, and commune levels. 
A total of 14.04 million indirect beneficiaries, approximately 90% of the national population,8
 were 
reached through national broadcasting on mass media platforms – far exceeding the original target of 
1,634,555: 
 BCC media campaigns were aired twice (April – July 2015, December 2015 – April 2016) across 
four television stations: CTN, MYTV, HMTV, and TV5. 
 Between April and July 2015, 11.9 million people were reached by the AIP Foundation television 
commercial. 
 Between December 2015 and April 2016, 14.04 million people across Cambodia viewed the BCC 
television campaign, 7.1 million of which were between the target ages of 15 and 45. 
Challenges During Implementation 
The most substantial challenge to the effective implementation of HSHO was the delayed enforcement 
of the national passenger helmet law. Promulgated in January 2015, the law was envisioned to go into 
effect six-months later. The operational design of HSHO therefore assumed that enforcement of the law 
would commence in July 2015 and would run alongside and reinforce other components of the program 
for a full 12 months. However, delays to enforcement resulted from: 
 Structural and leadership changes in the NRSC, the body responsible for coordinating the 
revision of the law and its rollout; 
 Long legislative processes to adopt a sub-decree to the law on penalties for traffic offenses; and 
 Limited capacity to ensure public awareness nationwide of changes under the law as well as the 
sub-decree for increased fines before the start of enforcement. 
These delays were beyond the capacity of HSHO to prevent or overcome entirely. However, positive 
results of HSHO efforts to mitigate these delays are illustrated as follows: 
 BCC was active in raising awareness of the upcoming enforcement measures, which had a 
crucial secondary effect of holding the government accountable to its voiced commitment to 
begin enforcement as planned. 
 Even with delays, enforcement of the passenger helmet law began less than a year after its 
promulgation – an achievement that speaks to the efficacy of EEC stakeholder capacity building, 
advocacy, and support. Enforcement of the earlier driver helmet law did not begin for almost 
two years after the law was passed. 
Less impactful challenges to implementation are described below: 
 Under SBP, it was difficult to fully engage with parents of primary school students due to limited 
 
8
 Assumes a national population of 15,577,000. See http://populationpyramid.net/cambodia/2015/ 
13
time availability and scheduling conflicts. In addition to receiving feedback to schedule 
workshops at more convenient times, future programs could incorporate shorter, more regular 
parent outreach sessions during the daily pick-up times at the school-gate, where parents often 
wait for their children for ten to fifteen minutes. 
 Under EEC, there were often minor but frequent delays for receiving signatures or approval of 
letters, plans, etc. due to long procedural processes required by government structures. A 
potential solution would be to reduce paperwork by encouraging more electronic 
communication amongst government stakeholders at the national level. Another suggestion 
would be to combine deadlines as best as possible, while continuing to follow up energetically 
with government counterparts. 
 For many years there has been limited funding and public interest in improving road safety. As a 
result, in addition to focusing on influencing behavior change through BCC efforts, HSHO has the 
additional challenge of influencing stakeholders and the public to recognize and prioritize road 
safety as a public health issue. 
Evaluation Design 
To evaluate the impact of grassroots level activities, HSHO selected 18 communes from six districts 
across the three target provinces to implement targeted intervention activities. For comparison 
purposes, six communes with similar characteristics to the target communes were selected as controls 
and monitored. 
Achievement of project goals and objectives was evaluated through comprehensive short-, medium-, 
and long-term indicators. While an overview appears below, please see Annex I: Monitoring and 
Evaluation Framework and Annex II: Indicator Reference Sheet for full details. 
 SBP: Helmet observations at the school gate; crash reporting for students; knowledge tests 
among students. 
 BCC: Tracking materials distribution and community engagement; measuring changes in 
reported knowledge, attitudes, and practices; media monitoring of television and radio 
broadcasting as well as social media airings. 
 EEC: Tracking materials distribution and stakeholder engagement; developing national and sub￾national action plans and receiving commitment letters; benchmarking passage and 
enforcement of the law; tracking enforcement activities. 
 Project-wide: Street-based helmet observations; extraction and analysis of road crash and victim 
information data with technical support from the US CDC; tracking press coverage. 
Two major challenges related to the evaluation design of HSHO are described below: 
1. The intervention had nationwide reach across all 25 provinces through both advocacy and mass 
media. However, appropriate measures were not in place to capture results beyond the three 
target provinces where grassroots and school-based campaigns took place. While official 
government data recorded in the Road Crash Victim and Information System (RCVIS) provides 
data on a national scale, it does not capture helmet use directly and there is a substantial data 
delay in capturing this information. 
2. The control groups were contaminated. Control and target communes were established within 
the three target provinces and could only capture differences in commune-level activities such 
14
as loudspeaker announcements and door-to-door campaigns that were only conducted in the 
target communes. Due to the nationwide scope of mass media and enforcement, as well as 
provincial and district level activities such as billboards, banners, tuk-tuk panels, and street￾based campaigns, controls were exposed to a portion of project activities, which could have 
increased control group helmet use rates. 
Moving ahead, evaluation tools should be designed to capture the impact of nationwide campaigns. 
However, future evaluation design must also take into consideration the resources required to conduct 
helmet observations of all representative groups at increased scale, as it can get costly to expand 
evaluation efforts. 
Improvements could also be made with variable selection: 
1. The design did not adequately anticipate the need to examine differences in helmet use rates 
along national and local roads. While AIP Foundation’s Monitoring and Evaluation manager was
able to parse this out retrospectively, it would be helpful moving forward to strategically 
conduct observations that can identify differences between these comparison groups. 
Additionally, a comparison of different national roads could help parse out what impact 
enforcement has on the increased helmet use observed along national roads in comparison to 
other confounding factors. 
2. The evaluation plan did not directly incorporate a variable to determine the impact of police 
enforcement on helmet use rates. In the future, the evaluation design for street-based helmet 
observations should include a variable to account for enforcement by placing some video 
cameras adjacent to police checkpoints and others in areas less frequently patrolled by police. 
Overall, the data collection process was accurate with slight infringements. Street-based helmet 
observations were sometimes conducted at locations near construction sites, which impeded traffic 
flow. In addition, school-based crash monitoring risks underreporting the true number of collisions, as 
primary school students often did not provide incident reports unless individually and regularly 
approached by teachers, who often do not have the capacity to do so. Official government data (RCVIS) 
risks being under reported as well, and there is a considerable lag in the availability of the most recent 
data. Some information that would be useful for more rigorously evaluating the impact of policy 
changes, especially enforcement, is not available to AIP Foundation, including the exact number of 
traffic police deployed; the exact number and frequency of checkpoints along national in comparison to 
local roads; and the level of training provided to traffic police on changes in the new road traffic law. 
Impact Evaluation Design 
Due to some of the limitations of the evaluation design referenced above, it is not possible to specifically 
determine the impact of nationwide activities. As a result, the impact evaluation analysis relies upon the 
increase in helmet use rates from baseline to end-line in the three target provinces only – inherently 
underestimating the true number of avoided casualties and losses across the twenty-two other 
Cambodian provinces. 
The cost analysis relies primarily on the human capital methodology, which equates the value of human 
life with the discounted market value of the output produced by an individual over an expected lifetime. 
It is perhaps the most commonly used methodology for adjusting the value of future earnings based on 
15
extensions or improvements to life. However, this methodology fails to recognize the cost of pain or 
suffering, or the benefit of pleasure and leisure. 
For this Report, the willingness to pay methodology is offered as an alternative. This method considers 
more than just workplace output and seeks to determine the value of a life based on an individual’s 
willingness to pay for reductions to the probability of death. The figures are based on global averages, 
which presents a particular challenge within the context of Cambodia’s developing economy.9
 To 
overcome methodological limitations of using willingness to pay calculations in the Cambodian context, 
interested donors could fund in-country surveys to get a more accurate estimate of the value of life as it 
pertains to the local economy. 
Please refer to Annexes III – VIII for more details on formulas, cost categories, and data sources. 
Results and Findings 
Short- and Medium-term Results 
All three components demonstrated strong success under both short-term and intermediate outcome 
indicators. 
School-Based Programs (SBP) 
The SBP short-term outcome is that students in target schools have improved awareness of the need to 
wear a helmet. From December 2014 to May 2016, the average score of students on the knowledge test 
increased from 56% to 88% at target schools. 
The SBP intermediate outcome is that more children at target schools wear helmets when traveling by 
motorcycle and bicycle as measured through school-based helmet observations. From baseline to end￾line, average helmet use among students across the 18 target schools increased from less than 1% to 
75% compared to a much less substantial increase from less than 1% to 4% among students at the 6 
control schools. See Figure 1 below. 
 
9
See “Valuation of Accident Reduction,” Institute for Transport Studies, University of Leeds, 2003, 
http://www.its.leeds.ac.uk/projects/WBToolkit/Note11.htm for further explanation
16
Behavior Change Communications (BCC) 
The survey evaluated the short-term outcome that motorcycle passengers in target areas have 
improved awareness of the need to wear a helmet. See Figure 2 below. From August 2014 to April 2016, 
the percentage of people surveyed from target communes who agreed that it was very important to 
wear a helmet as a passenger increased from 46% to 57%. Responses from control communes also 
increased from 43% to 65%, suggesting that commune-specific activities seemed to have a limited effect 
above and beyond broader geographic activities. 
The survey also measured the short-term outcome of the BCC campaign that motorcycle passengers in 
target areas have improved attitudes toward helmet use. From August 2014 to April 2016, people 
surveyed who said they intend to wear helmets as passengers increased from 86% to 94% in target 
communes and from 90% to 100% in control communes. This increase in helmet use across target and 
control communes reflects the impact of nationwide campaigns and district level BCC efforts. 
The intermediate outcome of the BCC campaign is that more motorcycle passengers in target areas 
report wearing helmets as measured through a knowledge, attitude, and behavior survey. From August 
2014 baseline to April 2016 end-line, respondents who reported always wearing a helmet as a passenger 
in the previous month increased from 11% to 40% across target communes. Control communes had 
similar increases, rising from 9% to 45%. 
Full topline and end-line reports on BCC efforts are included as Annex IX and Annex X respectively. 
4%
75%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Control Schools Target Schools
Figure 1: Change in Helmet Use at Schools
Control vs. Target Schools
August '14 May '16
<1% <1%
17
Enabling Environment Change (EEC) 
EEC’s short-term outcome indicators pertain to the creation of enforcement action plans. At a national 
level, EEC saw the successful adoption of the National Enforcement Action Plan for Passenger Helmet 
Use. EEC efforts at the provincial level have also spurred the approval of 2 out of 3 enforcement action 
plans and efforts at the district level have led to the approval of 4 out of 6 enforcement action plans. 
Under EEC, the intermediate indicator is the number of fines issued by traffic police for non-helmeted 
passengers. Between January and June 2016, 41,349 fines were issued in the three target provinces as 
compared to the 0 issued prior to the start of HSHO when there was no penalty assigned to passenger 
non-helmet use. 
Long-term Results 
Examination of long term results – i.e. changes in helmet use rates and the rates of fatality and injury –
help identify ways to best refine the model for effective, cost-efficient scaling. Observed helmet 
observation rates have been updated slightly from the previously submitted Behavior Change 
Communications and School-Based Program End-Line Evaluation Report submitted to USAID-DIV in June 
2016. Please see Annex XI for data from the street-based observations. Helmet observations were 
conducted in the six target districts; however, these district-level rates can be assumed to be 
representative of helmet use rates at the provincial level.10
Avoided losses 
As a result of successful enforcement efforts for adult passenger helmet use, which will be addressed in 
detail below, there was an increase in adult motorcycle passenger helmet use rates and a woodwork 
effect with driver helmet use rates. Based on these improvements, an estimated 349 drivers and adult 
passenger casualties were prevented across the three target provinces. These avoided casualties 
 
10 This assumption was discussed with the US CDC and reflects common practice. Other studies use less 
observation points to extrapolate to the provincial level. 
11%
45%
86%
40%
61%
94%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Always Wear a Helmet as a
Passenger
Believe It is Very Important to
Wear a Helmet as a Passenger
Intend to Wear Helmets as
Passengers
Figure 2: Change in Attitudes and Behaviors
Baseline to End-line 
August '14 April '16
18
translate to significant cost savings, as calculated using both human capital and willingness to pay 
methodologies. The human capital methodology, which was used originally for projections made during 
the HSHO planning stage and takes into account the cost of a fatality and the loss of future output, 
estimates that the change in adult helmet use rates led to cost savings of $3,089,316 USD. 
Separate analysis using a more robust willingness to pay methodology, which attempts to capture the 
value of pain and suffering avoided, the value of time lost due to illness, and the costs of medical 
treatment, offers cost savings of $4,309,159 USD. This methodology is generally viewed as more 
reflective of true costs than human capital, but its assumptions, reliant upon global data, face certain 
limitations within the context of Cambodia’s less developed economy as discussed above. 
Over the course of the HSHO project, adult motorcycle passenger helmet use rates in target provinces 
increased significantly from a baseline of 11.3% to an end-line of 36.0%. See Figure 3 below for the 
change in adult passenger helmet use for each target province and overall. All changes from baseline to 
end-line were significant. 
Based on the change in adult passenger rates and assuming that only adult passenger casualties were 
avoided, an estimated 97 casualties were prevented across the three target provinces, leading to cost 
savings of $859,243 USD. Please refer to Annex III for the human capital analysis. Using the alternate 
willingness to pay methodology offers cost savings of $1,166,194 USD. Please refer to Annex IV for the 
willingness to pay analysis. 
As shown in Figure 4 below, HSHO results also indicate a woodwork effect for drivers, with helmet use 
rates in the three target provinces increasing from 63.0% to 75.7% on average over the two-year 
program. 
11.6% 13.2%
7.1%
11.3%
42.9%
37.1%
20.2%
36.0%
0%
10%
20%
30%
40%
50%
Phnom Penh Kandal Kampong Speu Total
Figure 3: Change in Adult Passenger Helmet Use Rates
Baseline to End-line 
August '14 May '16
19
This increase in driver helmet use in the three provinces resulted in an estimated 252 avoided casualties, 
translating to an additional $2,230,073 USD saved based on the human capital methodology or 
$3,026,732 USD according to a willingness to pay framework. See Annex V and Annex VI for detailed 
calculations. 
While helmet use has also increased for children, nearly quadrupling from baseline, the improvement 
has been more muted and was not sustained after the public realized child helmet use had been 
excluded from the sub-decree related to fines and enforcement. Overall, combined adult and child 
passenger helmet use rates across the three target provinces increased from a baseline of 10.4% to an 
end-line of 33.4%. See Figure 5 below for changes in overall passenger helmet use. 
71.7%
55.9%
40.3%
63.0%
84.0%
69.0%
60.9%
75.7%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Phnom Penh Kandal Kampong Speu Total
Figure 4: Change in Driver Helmet Use Rates
Baseline to End-line 
August '14 May '16
11.0% 11.3%
6.4%
10.4%
40.3%
32.6%
19.7%
33.4%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
Phnom Penh Kandal Kampong Speu Total
Figure 5: Change in Helmet Use Rates for Child and Adult 
Passengers
Baseline to End-line 
August '14 May '16
20
By incorporating children into the impact evaluation analysis, the increase in overall passenger helmet 
use would lead to 107 avoided casualties in the three provinces, translating to an additional $947,768 
USD saved based on the human capital methodology or $1,282,428 USD according to a willingness to 
pay framework. See Annex VII and Annex VIII for detailed calculations. 
In addition to these estimates for injuries and fatalities avoided in the three provinces overall, school￾based crash monitoring found specifically that 332 children reported being involved in a bicycle or 
motorcycle incident while wearing a project helmet donated as part of SBP, with potentially life-saving 
effect. 104 of these children were passengers on motorcycles at the time of the crash. 
National roads saw greater improvement 
According to the RCVIS 2015 Summary Report included as Annex XII, 68% of road crashes occur on 
national roads. HSHO used its data to explore anecdotal evidence that enforcement activities were 
greater on these national roads than on local roads. The data, shown in Figure 6 below, supports this 
belief. National roads saw double the rate of change after the January start of enforcement than did 
local roads. 
However, it is important to note that different helmet use rates may be attributable, at least in part, to 
different attitudes regarding the dangers posed by: national versus local roads; traveling over longer 
distances; reaching higher speeds; or the perception of more extensive enforcement activities held on 
national roads as compared to local roads. It may be worthwhile to compare rates along various national 
roads to look at other explanations for differences in helmet use.
Decline in non-helmeted deaths and injuries 
Final per capita data on road safety injury and death rely on the official RCVIS 2016 Summary Report 
which combines data collected by the police and health centers, and will not be available until mid-2017. 
However, AIP Foundation worked with the Cambodian police to obtain national level police data to 
overcome this limitation. Analysis indicates a reduction in the rate of injury and fatality over time, as 
shown in Figure 7 below. 
8.0% 11.0% 9.4%
21.1%
23.7%
13.7%
17.2% 16.5%
36.9%
44.5%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Aug-14 Aug-15 Nov-15 Jan-16 May-16
Figure 6: Adult Passenger Helmet Use 
Local vs. National Roads
Local Road National Road
21
Closer Analysis of Results Including Lessons Learned and Next Steps 
Analysis of changes in helmet use rates in target provinces and a comparison of target and control 
groups over the course of HSHO project implementation reveals the following key takeaways: 
Enforcement mattered most 
First and foremost, enforcement of the passenger helmet law, which began in January 2016 after a 
number of delays, was catalytic for increasing helmet use rates. The EEC component of HSHO heavily 
supported the enforcement of the passenger helmet law by assisting with the development of national 
and sub-national enforcement action plans for traffic police, and contributed largely to the realization of 
the project’s anticipated spillover effect into control communes (i.e. where no grassroots activities took 
place directly). See Figure 8 for the effect of January 2016 enforcement in both target and control areas. 
 
1922
990
1430
793
Driver Deaths and Injuries Passenger Deaths and Injuries
Figure 7: Change in Non-Helmeted Deaths and Injuries 
2014 to 2016
Jan - June 2014 Jan - June 2016
25.6% Reduction 19.9% Reduction
11.9%
14.2%
13.4%
27.9%
33.2%
9.9%
14.8%
12.9%
30.0%
33.4%
0%
5%
10%
15%
20%
25%
30%
35%
40%
Aug-14 Aug-15 Nov-15 Jan-16 May-16
Figure 8: Adult and Child Passenger Helmet Use
Control vs. Target
 Control Target
22
BCC should discontinue grassroots efforts at the commune level
As is evident based on Figure 8 above, there was negligible change to passenger helmet use rates 
throughout the target areas prior to the start of enforcement in January of 2016. This suggests against 
continuing extensive BCC grassroots efforts in the future. From an EEC perspective, it would be advisable 
to retain BCC’s mass media campaigns, which were an effective mechanism for utilizing public 
expectation of pending enforcement to hold the government accountable to its voiced start date, 
thereby pre-empting any last minute government-initiated delays. It is also advisable to continue BCC 
efforts at the provincial and district levels given that these activities are less resource intensive and 
leverage the role of provincial and district authorities to disseminate information and oversee 
enforcement at a broader level. Additionally, helmet observation data from non-target provinces 
suggest that passenger helmet use rates have been less stable post-enforcement than the three HSHO 
provinces.11 This suggests that provincial and district level awareness activities may contribute to lasting 
behavior change alongside provincial EEC efforts and should be expanded to other provinces. 
SBP activities should focus on ‘model’ schools 
There is a significant difference between child helmet use rates in target and control communes prior to 
the start of enforcement as observed through commune-level observations, which strongly suggests 
that the SBP component effectively led to positive behavior changes. Please see Figure 1 above. 
However, SBP activities are labor and resource intensive. To continue to support helmet use in schools 
while recognizing cost limitations of scaling SBP activities, one school from every province could be 
selected to serve as a ‘model’ school for the province, receiving helmet donations and school-level 
interventions. This would allow AIP Foundation to continue to engage with relevant authorities and 
stakeholders while encouraging schools to contribute to child helmet use efforts by providing an 
example for best practices. 
Components of SBP should be incorporated under EEC 
With the scale down of SBP activities to ‘model’ schools, remaining efforts can be consolidated into the 
EEC component – namely, advocacy and action planning with the Ministry of Education to use school 
regulations as a soft enforcement mechanism nationwide. As a note, in rural and lower socio-economic 
areas, removing helmet donations to students through the schools may pose a hurdle to increasing child 
helmet use; however, this could serve as an opportunity for EEC to work with relevant government 
ministries to advocate for social responsibility efforts amongst private sector members, including helmet 
donations. 
 
11 Cambodia Helmet Vaccine Initiative 2016 Summary Report.
23
 
Children must be included into enforcement of fines 
A major point of concern for HSHO has been the exclusion of children from the enforcement of fines for 
the new passenger helmet law. While the start of enforcement in January led to an initial jump in 
helmet wearing rates amongst children, presumably due to the public’s assumption that fines for the 
new law would extend to children, there has been a subsequent decline in child helmet rates from 
January to May 2016, as evident in Figure 9 above. In comparison, adult passenger rates shown below in 
Figure 10, have increased over the same time frame. 
Comparison of Figures 9 and 10 between January and May 2016 thus demonstrates a strong need for 
continuing advocacy efforts to push for the inclusion of children into the sub-decree on fines, 
6.5% 10.0% 9.3%
19.0%
18.2%
5.7%
16.0%
12.2%
28.7%
22.5%
0%
5%
10%
15%
20%
25%
30%
35%
Aug-14 Aug-15 Nov-15 Jan-16 May-16
Figure 9: Child Passenger Helmet Use
Control vs. Target
 Control Target
13.0%
14.9% 14.3%
29.6%
36.0%
10.8%
14.6% 13.1%
30.3%
0%
5%
10%
15%
20%
25%
30%
35%
40%
Aug-14 Aug-15 Nov-15 Jan-16 May-16
Figure 10: Adult Passenger Helmet Use
Control vs. Target
 Control Target
24
supplemented by efforts to incorporate road safety into curriculum and uniform requirements in schools 
as well as increasing awareness of the importance of child helmet use through BCC campaigns. 
Woodwork effect seen on driver helmet rates 
A positive woodwork effect can be seen for driver helmet rates. See Figure 11 below. This was a 
reasonable expectation given that non-helmeted drivers would also incur a fine with increased 
enforcement efforts alongside any non-helmeted passengers. Additionally, BCC education campaigns 
also targeted drivers by focusing on the driver’s responsibility to protect their passengers. While the 
primary goal of this campaign was to increase helmet use amongst passengers, it may have served an 
additional purpose of raising awareness about the importance of wearing a helmet amongst drivers as 
well. This type of joint messaging about the importance of helmet use for all should be continued in 
future mass media campaigns, and moving forward there should be increased efforts to integrate 
drivers into activities aimed at increasing helmet use, particularly given that it can lead to substantial 
cost savings as discussed above. Please see Annexes V and VI for more details. 
Unquantified impact beyond intervention areas 
The HSHO program has also had unquantified impact extending beyond the three target provinces 
thanks to the nationwide implementation of the new passenger helmet law, as set out through EEC 
supported passage of the nationwide passenger helmet law and the National Enforcement Action Plan 
on Passenger Helmet Use. Based on the analysis discussed above, it is reasonable to assume helmet 
wearing rates increased in provinces throughout Cambodia as enforcement went into effect nationwide. 
Additionally, BCC mass media activities reached nationwide audiences, but the impact of these efforts 
are difficult to measure. However, research has shown that road safety mass media campaigns, when 
combined with other measures like enforcement, result in an average 8.5% reduction in crashes during 
the campaign, and after completion, crash reductions can increase to 14.8%.12
 
12 “Approach,” CAST. Belgian Road Safety Institute, http://www.brsi.be/en/road-safety/cast/approach/
58.7% 63.4% 62.6%
71.9%
64.1% 68.0% 66.4% 71.0%
76.7%
77.1%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Aug-14 Aug-15 Nov-15 Jan-16 May-16
Figure 11: Driver Helmet Use
Control vs. Target
 Control Target
25
Other key achievements 
A number of other impressive outcomes were achieved through the HSHO project, namely: January 
2015 promulgation of the new passenger helmet law, July 2015 passage of the sub-decree on fines, and 
January 2016 start of enforcement of the law. 
The attention raised by media, in cooperation with AIP Foundation’s other projects, was also notable. 
Prime Minister Hun Sen was featured prominently in the news with a photograph of him and his 
passenger wearing a helmet. Additionally, the United States Ambassador included a direct reminder 
about the new passenger helmet law in his holiday video message posted on social media. The 
government has also recently stated to media outlets that it has called for motorcycle manufacturers to 
seriously consider providing a free child helmet with every motorcycle sale, indicating potential private 
sector collaboration. These examples signify that helmet use, especially for passengers, is becoming a 
new priority in the country and is finally achieving the attention necessary to address such a widespread 
and costly problem. 
A closer look at achievements reached through advocacy efforts can be found in the separate Policy 
Report under this Milestone submission. Successes of each project component are also summarized in 
the case studies included as Annexes XIII – XV. 
Lessons learned for future funders and policymakers 
In the longer-term, AIP Foundation expects a steady rise in helmet wearing rates if enforcement 
activities, mass media campaigns, and school-based education programs are sustained. Based on the 
above results, HSHO issues the following recommendations to ensure continued improvement: 
 For development funders, there is an urgent opportunity to include “soft” road safety 
components aimed at improving road user behaviors alongside infrastructure improvements as 
Cambodia continues to develop. Of all international development aid offered to Cambodia, by 
far the most goes to the transportation sector: between 2013 and 2015, $995 million USD, or 
32% of all aid the country received, went to the transportation sector. However, the majority of 
these projects are grants or loans for road and infrastructure development, while insufficient 
resources are allocated to road safety initiatives.13
 
o Moving forward, infrastructure projects should require a portion of funding be 
dedicated to curbing the dangers posed by increased road development. 
 The toll of road crashes continues to counteract many of the gains Cambodia is making in 
development – including in the health sector and with poverty reduction. 
o Impact bond case studies and models for investment can be developed to attract new 
networks of donors focused on evidence-based models that will curtail the losses 
associated with road casualties. 
 There is unexplored space for greater engagement by private sector funders. 
o Corporations have the opportunity to fund helmet donations or subsidies for lower￾income groups as a complement to related public sector initiatives. 
o Major companies and organizations could also require helmet use both on and off 
company grounds through organizational policies and staff regulations, helping spread a 
culture of safety outwards. 
 
13 Council for Development of Cambodia
26
 For policy makers in Cambodia, it must be a priority to include children into “mainstream” 
helmet use. 
o This can be through both enforcement efforts and inclusion of children into the sub￾decree on fines, as well as through the incorporation of helmet use in school curriculum 
and uniforms nationwide. 
 Helmet quality is a major issue in Cambodia. Although a Cambodian helmet quality standard was 
set through legislation passed in 2010, large numbers of helmets on the market are of sub￾standard quality, which means they offer poor protection and may even shatter on impact, 
worsening injuries during a crash. 
o As there are no helmet test centers in Cambodia, there is an opportunity for public and 
private sector collaboration to provide funding for the construction and operation of 
these centers. 
Key staff attributes 
The sharp, on-the-ground knowledge amongst the staff of the road safety situation in the country was 
key to establishing the credibility necessary to engage with stakeholders. As a caution for scaling, it may 
be difficult to effectively implement this model in countries where an existing NGO or team does not 
already have strong contextual understanding and established working relationships with relevant 
stakeholders. See discussion in Stakeholder Engagement above. 
Cost-effectiveness & Competitive Landscape 
Cost-Effectiveness 
USAID-DIV invested $635,993 USD in the HSHO program, which has realized the below cost-savings in 
the three target provinces: 
Table 2: Realized Cost Savings 
Increase in Helmet Use 
Among: 
Methodology Cost Savings (USD) Savings per Dollar 
Invested (USD)
Adult Passengers + Drivers Human Capital $3,089,316 $4.86
Adult Passengers + Drivers Willingness to Pay $4,309,159 $6.78
Adult Passengers Human Capital $859,243 $1.35
Adult Passengers Willingness to Pay $1,166,194 $1.83
Drivers Human Capital $2,230,073 $3.51
Drivers Willingness to Pay $3,026,732 $4.76
Adult + Child Passengers Human Capital $947,768 $1.49
Adult + Child Passengers Willingness to Pay $1,286,343 $2.02
Please refer to Annexes III – VIII for additional details of the cost savings calculations. 
It is important to note again that this underestimates the true cost savings realized through the HSHO 
project. Given that there were negligible differences between increased helmet use amongst adult 
passengers and drivers in the target and control communes throughout the three target provinces, likely 
due to the nationwide impact of passenger helmet law enforcement initiated with EEC support, it is 
reasonable to assume that the remaining twenty-two provinces experienced similar increases. As such, 
the avoided casualties and associated losses are likely substantially higher. 
27
Competitive Landscape 
As is clear through the above analysis of the two-year HSHO program, helmets provide a quick and cost￾effective solution to reducing injuries and fatalities. Other strategies or interventions, such as long-term 
projects aimed at infrastructure, public transportation, or post-crash care upgrades, are important 
measures to improving the road safety landscape in Cambodia alongside efforts to increase helmet use; 
however, these measures may be difficult to implement quickly and at low cost – allowing for lives to be 
lost on the roads every day in the interim. 
Additionally, helmet use is more effective than alternatives at preventing road casualties; for example, 
research indicates that while enforcement of a drink-driving law can reduce the number of road deaths 
by 20%,14 helmet use reduces the number of deaths by 42%15 – leading to significant improvement in 
outcomes and avoided losses. 
The HSHO project is also on par with other public health issues in terms of cost-savings provided by 
every dollar invested. According to some analyses, every dollar invested in controlling malaria in Africa 
provides a five-dollar gain.16 Similarly, research into HIV prevention programs in Canada estimated that 
each dollar invested in these programs and services saved five dollars in future costs.17 The cost savings 
attributable to the combined increase in driver and passenger helmet use resulting from the HSHO 
project is in line with these other interventions. Given that the presented cost savings for the HSHO 
project ignore increases to helmet use in the twenty-two provinces benefiting from national activities, it 
is likely that the true comparison would reveal the HSHO intervention to be even more favorable. 
Project Improvement and Scaling Plan 
At the start of the project, the AIP Foundation team imagined that HSHO would scale-up through the 
public sector, maintaining and expanding all three components of the program while recognizing that 
the amount of funds allocated to helmet donations or subsidies should decrease. Based on experiences 
implementing the program over the past two-years, AIP Foundation suggests a revision of the current 
components to best scale the program in the next three to five years: 
 Due to the woodwork effect seen for drivers, scale-up should involve coordinated efforts to 
increase helmet use for both drivers and passengers at once, now that passengers are equally 
included in the law. 
 Results indicate clearly that support for enforcement through EEC efforts was most effective at 
increasing helmet use rates, and its advocacy and capacity building activities should be 
intensified at both national and sub-national levels. As Cambodia’s economy continues to grow 
 
14 “Global Status Report on Road Safety 2015,” World Health Organization.
15 Liu, Bette C, Rebecca Ivers, Robyn Norton, Soufiane Boufous, Stephanie Blows, and Sing Kai Lo. “Helmets for 
Preventing Injury in Motorcycle Riders.” In Cochrane Database of Systematic Reviews, edited by The Cochrane 
Collaboration and Bette C Liu. Chichester, UK: John Wiley & Sons, Ltd, 2008. 
16 “Costs and Benefits of Investment in Malaria Control, Elimination, and R&D,” Global Malaria Action Plan for a 
malaria-free world, http://www.rollbackmalaria.org/microsites/gmap/2-5.html 
17 “Study finds large savings from investment in community-based HIV prevention programs,” CATIE, 8 July 2015, 
http://www.catie.ca/en/catienews/2015-07-08/study-finds-large-savings-investment-community-based-hiv￾prevention-programs 
28
alongside much of the region, more people will acquire motorcycles or other motorized 
vehicles, which will only worsen the already chaotic situation. 
o It will be essential to improve the capacity and planning capabilities of traffic police and 
other relevant stakeholders in preparation for these changes. 
o EEC efforts should continue to focus on enforcement of both driver and passenger 
helmet use nationwide through the development of provincial level action plans, given 
that helmet use rates in non-HSHO target provinces such as Siem Reap have been much 
less stable since the start of enforcement in January 2016.18
o For Cambodia, focus should be placed on advocating to include children into the sub￾decree on enforcement of fines as well as on increasing stringent enforcement of the 
law nationwide through development of sub-national level action plans. 
 SBP components should be scaled to one ‘model’ school in every province to serve as an 
example for others while still allowing AIP Foundation to maintain contact with key 
administrators to support broader child helmet use efforts. 
 EEC should be expanded to include aspects of SBP’s focus on child helmet use. There is currently 
an Education Action Plan for schools that has been finalized by a technical working group, which 
would require that schools conduct awareness activities for students and parents and also host 
regular road safety education activities including annual helmet use events and weekly road 
safety reminders. EEC should advocate the MoEYS to approve and implement the action plan 
and other curricular reforms as soft enforcement mechanisms. 
 EEC advocacy efforts should be bolstered by BCC mass media campaigns via both television and 
radio channels to maintain and improve public awareness nationwide. 
 BCC grassroots activities at the commune level should be discontinued, as they did not lead to 
dramatically improved behaviors. However, BCC activities at the provincial and district levels 
should be maintained to support post-enforcement passenger helmet use rates across non￾HSHO target provinces. 
 Based on experiences with monitoring and evaluation in HSHO, there are a number of changes 
that could be implemented during a scale-up of activities. 
o Scaling nationwide removes the need for controls, which overcomes the issue of the 
impurity of control groups in HSHO but poses challenges for cost-effective monitoring. 
o There can be improved variable selection to isolate key factors that may influence 
helmet use, which would help determine the impact of those factors. Some examples of 
comparisons that could be drawn through the street-based observations include 
comparing helmet use rates at night and during the day, as well as along roads with or 
without enforcement checkpoints. 
HSHO intervention areas can be monitored as a separate group to examine the longer-term effects of 
the two-year project. Continued monitoring will also identify whether the improved knowledge, 
attitudes, and behavior attributed to BCC activities translates to higher helmet wearing rates in the long￾term, given that behavior change requires time. 
While much of the above discussion focuses on how lessons learned from the HSHO project over the 
past two-years can guide the scaling process in Cambodia, the key takeaways and lessons learned from 
 
18 Cambodia Helmet Vaccine Initiative 2016 Summary Report. 
29
HSHO may be generalized to other country contexts where: motorcyclists comprise a high percentage of 
road fatalities and injuries; there is a need to fill gaps in legislation, policy, or enforcement, including 
issues with coordination of government bodies; and helmet interventions are more viable than costly 
infrastructure renovations in the short to mid-term time frame, particularly in rapidly developing, low￾to middle-income countries. 
AIP Foundation hopes to apply this refined version at scale in the next three to five years in Cambodia as 
well as in other countries facing similar challenges – particularly to support the Post-2015 Sustainable 
Development Goals (SDGs), which include a target to reduce road deaths by half by 2020. To achieve 
this target in Cambodia, it has been calculated that helmet use must be increased to prevent head 
injuries and the loss of 3,950 lives by 2020.19 In preparation for this endeavor, AIP Foundation has 
secured funding from numerous partners including the FIA Foundation and The UPS Foundation. The US 
CDC has also committed to providing technical support. However, these partners will be unable to 
provide adequate funding and resources for implementation of all the necessary activities at national or 
multinational scale, so supplementary funding sources will be necessary for continued efforts. 
With the additional years spent building government capacity and developing handoff strategies during 
a three to five year scale up period, AIP Foundation believes that many elements of the refined project 
can be sustained through public sector channels in the subsequent years. The Cambodian government 
has shown commitment to addressing the crisis on the roads, providing nearly half of the funds – almost 
$3 million USD – to deliver the NRSC’s National Road Safety Action Plan and in 2016, additional 
government funding is enabling the purchase of new equipment to support enhanced enforcement 
activity. In May 2016, the government announced that they are also considering allocating funding to 
support initiatives from the Provincial Road Safety Committee starting in either 2017 or 2018. 
AIP Foundation has identified a number of government stakeholders that could incorporate aspects of 
the refined HSHO model into their responsibilities after completion of a three to five year scaling 
process: 
Table 3: Stakeholder Roles in Scale-Up
Stakeholder Activities
National Road Safety 
Committee 
Increase prioritization of addressing road safety risks, as has already been 
seen based on the staff members assigned to the NRSC. Require and 
enforce government staff helmet use. Increase funding for road safety and 
distribute funds to each provincial road safety committee. Responsible for 
coordinating the support and engagement from public and private sector
on road safety issues.
Department of Traffic 
Police and Public Order, 
National Police, Ministry 
of Interior
Strengthen their enforcement of non-helmeted motorcyclists including 
non-helmeted child passengers based on capacity building efforts made 
during the 3–5 year scale-up with AIP Foundation support.
 
19 Calculation conducted by Handicap International and the Institute for Road Safety Research (SWOV), The 
Netherlands, 2010 
30
Ministry of Education, 
Youth, and Sport
(MoEYS)
Responsible for the renewal of the National Action Plan to promote helmet 
use among students and educators by continuing to require that all 
schools, including private schools, implement and update road safety 
curriculum and incorporate helmet use as part of the school uniform.
Ministry of Information Continue to promote BCC media campaign activities by distributing road 
safety messages nationwide primarily through state media channels.
District Road Safety 
Working Groups
Take the lead with developing district-level helmet action plans and 
ensuring road safety messages can be effectively distributed to local 
community. Ensure sustainability of action plan implementation by 
identifying funding sources ongoing efforts.
 
Annexes 
Annex I: Monitoring and Evaluation Framework 
Annex II: Indicator Reference Sheet 
Annex III: Cost Savings from Increased Adult Passenger Helmet Use Using Human Capital Methodology 
Annex IV: Cost Savings from Increased Adult Passenger Helmet Use Using Willingness to Pay 
Methodology 
Annex V: Cost Savings from Increased Driver Helmet Use Using Human Capital Methodology 
Annex VI: Cost Savings from Increased Passenger Helmet Use Using Human Capital Methodology
Annex VII: Cost Savings from Increased Passenger Helmet Use Using Human Capital Methodology 
Annex VIII: Cost Savings from Increased Passenger Helmet Use Using Willingness to Pay Methodology 
Annex IX: Behavior Change Communications End-line Study Topline Report – May 2016 
Annex X: Behavior Change Communications End-line Evaluation Report 
Annex XI: Helmet Observations across Three Target Provinces 
Annex XII: RCVIS 2015 Summary Report 
Annex XIII: School-Based Program Case Study 
Annex XIV: Behavior Change Communications Case Study 
Annex XV: Enabling Environment Change Case Study 
Annex XVI: Feedback to USAID-DIV 
Annex XVII: Head Safe. Helmet On. Infographic