املجلد العرشون العدد الثامن
املجلة الصحية لرشق املتوسط
Seat-belt use among drivers and front passengers: an observational study from the Islamic Republic of Iran F. Sadeghnejad,1 S. Niknami,1 A. Hydarnia 1 and A. Montazeri 2
دراسة مالحظة من مجهورية إيران اإلسالمية:استخدام السائقني وركاب املقعد األمامي حلزام السالمة ً عالي ـ ـوادث ـبب حـ ـوت بسـ ـن املـ ـات الشــديدة ومـ ـن اإلصابـ ـة مـ ة للوقايـ ـر الوسـ ـن أكثـ ـامة مـ ـزام السـ ـن أن حـ ـم مـ ـى الرغـ عـ:اخلالصــة َّ ـائل ف ـة ـتخدام أحزمـ ـدل اسـ ـاس معـ ـة إىل قيـ ـذه الدراسـ ـدف هـ وهتـ.ـداءه ـون ارتـ ـة هيملـ ـدان الناميـ ـن البلـ ـر مـ ـركاب يف الكثـ ـائقني والـ ـإن السـ فـ،ـرق الطـ ـة مركبـ7718 ـملت ـي شـ ـارشة التـ ـة املبـ ـة للمالحظـ ونتيجـ.ـامية ـران اإلسـ ـة إيـ يف مجهوريـ،ـران ـك يف طهـ ـى ذلـ ـر عـ ـي تؤثـ ـل التـ ـامة والعوامـ السـ ً ـوائي ـت وكانـ.ـان ـزام األمـ ـدوا حـ ـد ارتـ ـي قـ ـد األمامـ ـركاب يف املقعـ ـن الـ مـ% 43.79ـائقني و ـن السـ مـ% 77.9 ـإن ـران فـ ا يف طهـ ـارة عشـ ـع خمتـ يف مواقـ ً ولكــن أقــل مــن الرجــال عندمــا جيلســن كــركاب يف املقعــد،النســاء أكثــر اســتخداما حلــزام األمــان مــن الرجــال أثنــاء قيادهتــن للمركبــة ً ـطة منخفض ـ .ا ـرة واملتوسـ ـل الكبـ ـات النقـ ـة يف مركبـ ـد األماميـ ـائقني وركاب املقاعـ ـن السـ ـان بـ ـزام األمـ ـداء حـ ـدالت ارتـ ـت معـ وكانـ.ـي األمامـ ً ـخص ً ـم دائـ ـباب ـا األسـ أمـ،ـادة ـاء القيـ ـامة أثنـ ـزام السـ ـدون حـ ا يرتـ ـن إهنـ ـن املواطنـ مـ% 62.4 ـال قـ،ا شـ666 ـع ـات مـ ـتقلة باملقابـ ـة مسـ ويف دراسـ ً ـر إبالغـ ـن ـل حتسـ ـن أجـ ومـ.ـون ـرام القانـ واحـ،ـات ـن اإلصابـ ـوف مـ واخلـ،ـات ـع املخالفـ ـب دفـ ـي جتنـ ـان فهـ ـزام األمـ ـتخدام حـ ـا السـ ا عنهـ األكثـ ً ً .ـات ـن األولويـ ـك مـ ـل ذلـ وجعـ،ـاس ـة النـ ـف عامـ ـن مصحوب ـا بتثقيـ ـون تفعي ـا للقوانـ ـرح الباحثـ يقـ،ـان ـزام األمـ ـتخدام حـ اسـ ABSTRACT Although seat-belts are the most effective means of preventing severe injuries and deaths from road accidents, drivers and passengers in many developing countries neglect to wear them. This study aimed to measure the rate of use of seat-belts and factors affecting their use in Tehran, Islamic Republic of Iran. In direct observations of 7718 vehicles at randomly selected sites in Tehran, 77.9% of drivers and 43.7% of front passenger had seat-belts fastened. More women used seat-belts than did men while driving but fewer as front-seat passengers. Rates of seat-belt wearing among both drivers and front passengers of vans and pick-up vehicles was low. In a separate interview study of 666 citizens, 62.4% stated that they always wore seat-belts while driving. The most frequently reported reasons for using seat-belts were avoiding fines, fear of injuries and respecting the law. To improve seatbelt use, it is recommended that law enforcement accompanied by public education should be a priority.
عيل منتظري، علريضا حيدرنيا، شمس الدين نيكنامي،فاطمة صادقي نجاد
Utilisation de la ceinture de sécurité chez les conducteurs et les passagers assis à l'avant : étude d'observation en République islamique d'Iran RÉSUMÉ Le port de la ceinture de sécurité est le moyen le plus efficace pour la prévention des traumatismes sévères et des décès dans les accidents de la circulation. Pourtant, les conducteurs et les passagers de nombreux pays en développement négligent cet acte. La présente étude visait à mesurer le taux d'utilisation de la ceinture de sécurité et les facteurs influant sur celle-ci à Téhéran (République islamique d'Iran). À partir de l'observation directe de 7718 véhicules sur des sites sélectionnés aléatoirement à Téhéran, il a été constaté que 77,9 % des conducteurs et 43,7 % des passagers assis à l'avant avaient bouclé leur ceinture. Les conductrices étaient plus nombreuses à mettre leur ceinture que les conducteurs mais moins nombreuses à porter la ceinture de sécurité en tant que passagères assises à l'avant. Dans les fourgons et les camionnettes, les taux d'utilisation de la ceinture chez les conducteurs comme chez les passagers des sièges avant étaient faibles. Dans une étude par entrevues distincte au cours de laquelle 666 personnes ont été interrogées, 62,4 % ont déclaré toujours porter leur ceinture de sécurité lorsqu'elles conduisaient. Les motifs les plus fréquemment évoqués pour justifier le port de la ceinture étaient les suivants : éviter les amendes, craindre les traumatismes et respecter la loi. Afin d'améliorer le port de la ceinture de sécurité,il est recommandé que l'application de la loi et l'éducation du public deviennent des priorités. Department of Health Education. School of Medical Sciences, Tarbiat Modares University, Tehran, Islamic Republic of Iran (Correspondence to S. Niknami: niknamis@modares.ac.ir). 2Mental Health Research Group, Health Metrics Research Centre, Iranian Institute for Health Science Research, Academic Centre for Education, Culture and Research, Tehran, Islamic Republic of Iran. 1
Received: 19/06/13; accepted: 16/01/14
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Introduction Fatalities and injuries caused by road traffic crashes are among the main challenges of public health (1). In the Eastern Mediterranean Region overall the fatality rate is about 26.4 per 100 000 people, while in the Islamic Republic of Iran fatalities from road accidents are 39 per 100 000 (1,2). The United Nations declared the years 2010–2020 as the Decade of Action for Road Safety, and asked its Member States to pay close attention to the main risk factors for road traffic injuries (3). Recent studies have found that three-fifths of road accidents are due to behavioural factors (4) and among the indicators of the Road Safety Development Index, road users’ behaviour is at the heart of road safety development (5). Wearing a safety seat-belt is considered the main factor in reducing the severity of vehicle accident injuries (1,6). It has been shown that the use of seat-belts reduces the risk of death in drivers and front-seat passengers by about 40% to 50% and the severity of injuries by about 50% (7). In the Islamic Republic of Iran about 87.6% of road traffic injuries are head injuries (8,9) and, in view of the low quality of management after accidents (10,11), we should consider more seriously protective measures such as seat-belt use to reduce the severity of injuries and prevent deaths (12). According to a recent survey, seat-belt wearing was found to be the most important factor affecting road safety in the Islamic Republic of Iran (13). Unfortunately, previous studies have shown the rate of seat-belt use in the country is still very low. In 2009 only 35% of Iranian people were using a seat-belt (14). Recent studies have estimated safety-belt use at about 52% to 63% (15), whereas the rate in developed countries is over 93% (7). Tehran, with over 11 million population and 4 million vehicles, is one of the busiest capitals in the world. The 492
incidence of unintentional injuries in Tehran is 28.1 per 1000 people, half of which are related to traffic accidents (16). The Iranian legal medicine organization reported that from March 2011 to March 2012, only in Tehran province, 1609 people died in traffic accidents and nearly 34 000 people were injured. According to the traffic police of Tehran, among all crash fatalities in 2011, only 30% had fastened seat-belts, and the main reason (more than 59% of cases) for fines for road traffic violations of Tehran drivers was not fastening seat-belts (17). Over 75% of traffic fatalities occurred in the inner city. In other words, Tehran is the only province in the Islamic Republic of Iran in which inner-city traffic fatality is higher than outside the city limits (18). The current study is part of a larger study that aimed to identify the epidemiological, environmental and behavioural determinants of safety-belt use among people living in Tehran in order to develop a theory-based educational intervention. The main study is currently underway, and the results are yet to be published. Thus, the particular objectives of this study was to observe current conditions and determine common reasons and factors related to use and non-use of safety-belts in Tehran, Islamic Republic of Iran.
method. First, we divided Tehran into 5 major geographical regions (north, south, east, west, and centre). Then, from each region, 2 roads were selected randomly from the list of all roads in the region (in all 10 roads). In addition, due to the importance of highways in the traffic flow of Tehran 1 of the inner-city highways was selected. The data were collected by an observational checklist specially designed for this study guided by the principle documents of the WHO (7), the Centers for Disease Control and Prevention (19) and the National Highway Traffic Safety Administration (20,21). A team of trained observers recorded the type of vehicle, and the sex and estimated age of drivers and front-seat passengers and whether they were wearing a seatbelt or not. The observations were planned from 7 to 12 July 2012 for 6 days (Saturday to Thursday) from 08:00 to 09:00 hours (at peak hours) and for all lanes (i.e. outer, middle and edge) in a road. The data were analysed using a descriptive reporting on numbers and frequencies and the chi-squared test for comparing categorical data. Interview-based study
Methods This was a cross-sectional study of the use of seat-belts by people living in Tehran. It consisted of 2 parts: an observational study to obtain an estimation of seat-belt use among drivers and front passengers while on the road; and an interview-based survey about individuals’ reasons for wearing and not wearing seat-belts. Observational study
We selected 11 observation sites by using a stratified multistage sampling
A brief interview was carried out with pedestrians at 11 sites (as indicated above) for 1 week from 09:00 to 10:00. They were approached in the street and interviewed by trained interviewers. The only criterion for inclusion was the consent of the participant. For data collection, the research team developed a semi-structured questionnaire and a team of experts assessed its content validity (22). We asked each participant to indicate how often he or she used a vehicle seat-belt (either as a driver or the front passenger). Response categories ranged from always to never. Then they were asked about reasons for using and
املجلد العرشون العدد الثامن
املجلة الصحية لرشق املتوسط
not using safety-belt. The interviewees could choose more than 1 response from a list of different options. We used descriptive statistics with numbers and frequencies to report on frequency of seat-belt use and reasons for using or not using seat a belt while driving.
Results Observational study
In all we observed 11 483 individuals (7718 drivers and 3765 front-seat passengers). Most drivers were male (90.2%), whereas only 62.9% of front passengers were men (Table 1). Our observations showed that 77.9% of drivers were using a seatbelt. The seat-belt use in drivers and front passengers by age, sex, vehicle type and observation site are shown in Table 2. The rate of seat-belt wearing among women drivers was higher than among men (81.0% versus 77.5%). The seat-belt use of taxi and private car drivers was high (81.9% and 80.6% respectively), but among pick-up and van drivers, seat-belt use was lower (52.8% and 61.0% respectively). Wearing safety-belts among drivers varied across different observation sites of the city. The highest rate of seat-belt use was reported in the centre while the lowest was in the east (92.5% and 65.3% respectively). The overall rate of seat-belt use among front-seat passengers was 43.7%. The use of seat-belts in pick-up trucks and van front-seat passengers was low (31.6% and 30.0% respectively) (Table 2). The highest rate of front-seat passengers’ seat-belt use was on the highway and the lowest was in the eastern region (64.9% and 34.3% respectively). We analysed the relationship between demographic variables and the use of seat-belts among drivers. The results showed that there were significant relationships between seat-belt
wearing and age (P < 0.002), sex (P < 0.017), vehicle type (P < 0.001) and observation site (P < 0.001) (Table 2). Also the results obtained from chisquared tests showed significant relationships between front passengers’ seat-belt wearing and seat-belt use by the drivers (P < 0.001), type of vehicle (P < 0.001) and observation site (P < 0.001). There were no significant relationships for other variables studied (age P < 0.21 and sex (P < 0.12) for passengers. Interview-based study
In the second part of the study, 666 pedestrians were approached during the identified time for interviews. Of these, 62 respondents indicated that they never drove a vehicle. Thus the remaining 604 individuals took part in the study and were interviewed (no
one refused to participate). The mean age of respondents was 33 (standard deviation 13.2) years old, and 74.5% were male (Table 3). When we asked about the effectiveness of seat-belt in preventing injury, 81.2% said that seat-belts were very effective. Among people who had a driving license and used to drive, 62.4% stated that they always fastened their safety-belt while driving. Further analysis of the data showed significant relationships between geographic location of interview (P < 0.001), age (P < 0.001), sex (P < 0.001), education (P < 0.014) and self-reported seat-belt use while driving (Table 4). Also 55.6% of respondents stated that they always used seat-belts as a front passenger. The results showed significant relationships between age (P < 0.001), interview site (P < 0. 001) and
Table 1 Demographic distribution of the drivers and front-seat passengers in the observational study Variable No. Sex Male Female Estimated age (years) 6–17 18–20 21–35 36–55 ≥ 56 Type of vehicle Taxi Private car Van Pick-up Observation site North South West East Centre Highway n/a = not applicable.
Drivers (n = 7718) % 90.2 9.8 – 1.0 45.5 45.4 7.9 28.5 59.5 3.3 8.8 14.8 18.1 18.1 18.4 16.3 14.2
Front passengers (n = 3765) No. 2370 1394 32 309 1920 1237 265 1309 1985 158 313 494 806 457 927 591 490 % 62.9 37.1 0.9 8.2 51.0 32.9 7.0 34.8 52.7 4.2 8.3 13.1 21.4 12.1 24.6 15.7 13.0
6964 756 n/a 79 3512 3501 606 2197 4594 251 678 1140 1400 1400 1420 1260 1100
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Table 2 Use of vehicle safety seat-belt among drivers and front-seat passengers in the observational study by age, sex, type of vehicle and region Variable Yes No. Total Sex Male Female Estimated age (years) 6–17 18–20 21–35 36–55 ≥ 56 Type of vehicle Taxi Private car Van Pick-up Observation site North South West East Centre Highway n/a = not applicable.
Drivers Wearing seat-belt No % 77.9 77.5 81.0 – 63.3 79.2 77.0 77.4 81.9 80.6 61.0 52.8 77.1 73.1 77.8 65.3 92.5 84.3 No. 1708 1564 144 n/a 29 730 804 137 398 892 98 320 261 376 311 493 94 173 % 22.1
P-value
Front passengers Wearing seat-belt Yes No. 1647 % 43.7 44.7 42.1 40.6 41.4 45.4 41.6 45.7 36.7 51.5 31.6 30.0 36.2 53.6 42.2 34.3 35 64.9 No. 1647 1311 807 19 182 1049 723 144 829 962 108 219 315 374 264 609 384 172 No % 43.7
P-value
6010 5398 612 n/a 50 2782 2696 469 1799 3700 153 358 877 1024 1089 927 1166 927
< 0.017 22.5 19.0 < 0.002 – 36.7 20.8 23.0 22.6 < 0.001 18.1 19.4 39.0 47.2 < 0.001 22.9 26.9 22.2 34.7 7.5 15.7 179 432 193 318 207 318 63.8 46.4 57.8 65.7 65.0 35.1 480 1023 50 94 63.3 48.5 68.4 70.0 13 127 871 514 121 59.4 58.9 54.6 58.4 54.3 1059 587 55.3 57.9
0.12
0.21
< 0.001
< 0.001
self-reported use of seat-belt as a front passenger. The reasons for using and not using a safety-belt are shown in Table 5. Most of the respondents stated more than 1 reason. The most common reasons for wearing a seat-belt were avoiding fines (62.7%), fear of injuries (54.4%) and respecting the law (49.5%). The most common reasons for not wearing a seat-belt were lack of risk awareness (51.4%), lack of regulation awareness (40.4%) and not being in the habit of wearing a seat-belt (40.4%). About 15% of the people interviewed also indicated laziness or dirtiness or it not being necessary for short trips as other reasons for not wearing a safety seat-belt. 494
Discussion This was a combination of an observational and an interview-based study. The findings showed that safety-belt use was low among drivers in Tehran and was lower still among front passengers. In general the use of vehicle seatbelts in the Islamic Republic of Iran is a very recent phenomenon. Using seat-belts by front and back passengers has been the law only since 2005. Thus we can argue although there have been improvements in using seat-belts in the country, still there is an urgent need for serious law enforcement and implementing educational programmes for those who neglect to use seat-belts.
We observed that about 90% of taxi drivers were wearing seat-belts which is considerably higher than a previous study from Tehran which reported that only 20% of taxi drivers were wearing seat-belts (17). Such different observations might be explained by several reasons. First, it could be the result of better law enforcement by police in recent years in the inner-city, particularly in the central areas. Secondly, changes to the type of vehicles used as taxi-cabs might be a factor. Taxis in Tehran were recently changed to newer, more modern cars. Thirdly, the geographical location of observations and type of vehicle also may explain why there were such differences in reports. Unfortunately, due to lack of information
املجلد العرشون العدد الثامن
املجلة الصحية لرشق املتوسط
Table 3 Demographic distribution of citizens in the interview study (n = 604) Variable Sex Male Female Age (years) 18–20 21–35 36–55 ≥ 56 Education No education 6 years Diploma Upper diploma BA/BS degree MA/PhD degree Interview site North South West East Centre Highway 90 96 116 95 111 96 14.9 15.9 19.2 15.7 18.4 15.9 22 91 204 27 202 58 3.6 15.1 23.8 4.5 33.4 9.6 32 381 172 18 5.3 63.1 28.5 3.0 450 154 74.5 25.5 No. %
about these it is impossible to indicate to what extent these factors played a role. Based on the observational study, women used seat-belts more than men while driving but used seat-belts less as front-seat passengers. Other investigators reported similar findings (23,24). We observed that only 42.1% of women were wearing a seat-belt as a front passenger. This low rate of seat-belt use might be due to several reasons including embarrassment, types of women’s clothing or concerns about the dirtiness of some safety-belts (as some citizens stated in interviews). Interestingly we found that selfreported seat-belt use was lower than in direct observations (62.4% versus 77.9%), whereas previous researchers found that self-reported seat-belt use was overestimated (25,26). This underestimation of seat-belt use in Tehran needs further investigation.
However, 2 explanations can be put forward to explain the findings. First, interviews and observations were obtained from different individuals. Secondly, it can be argued that selfreported seat-belt use and observations could be very close when the seat-belt use is common practice in such communities (27,28). When we asked people’s opinions about the effectiveness of seat-belts in preventing injury, more than 80% of respondents declared that seat-belts were very effective. This implies a high rate of perceived efficacy of seat-belt use and can be considered in planning educational programmes for injury prevention. Nearly half of the respondents in interviews said fear of injury was the main reason for safety-belt use, indicating that the perceived risk was high and as such it can support the use of fear appeal strategies in designing safety seat-belt use campaigns (29). In
addition, the current study found that avoiding fines was the main reason for seat-belt use. This clearly indicates that law enforcement is an effective measure for promoting safety in vehicles. The respondents also stated that there was no need to use safety-belts in the inner city and for short trips. This attitude has been noted in other studies (30), but considering that most of the road accident fatalities of Tehran Province occur in urban areas it is essential to plan training programmes to change this attitude. Although the average rate of safetybelt use among drivers and front passengers in Tehran was close to 62% (77.9% in drivers and 43.7% in front seat passengers), and has increased during recent years, it is still less than those reported from developed countries such as Australia, Finland and Germany, where over 90% of people use seat-belts (7). This study had some limitations. The descriptive nature of the study could be a limitation. In addition, although we tried to obtain a large enough sample size in the study, it seems that studies of similar topics might need a bigger sample size. Another criticism of the sampling is that 62 respondents who did not drive were excluded from the interviews even though their opinions as passengers would also be valid. To interpret the findings with more precision it may be necessary to sample the expected volume of traffic/people at the time of observation. Finally, if possible, it would be better to observe and interview the same people to ensure that the interpretation of the results was more straightforward.
Conclusions The findings showed that a considerable proportion of people in Tehran, whether drivers or front-seat passengers, do not use seat-belts. To improve 495
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Table 4 Citizens’ self-reported vehicle seat-belt use in the interview study by sex, age, education and region (n = 604) Variable Never No. Total Sex Male Female Age (years) 18–20 21–35 36–55 ≥ 56 Education No education 6 years Diploma Upper diploma BA/BS degree MA/PhD degree Interview site North South West East Centre Highway 1 0 0 1 1 1 1.1 0.0 0.0 1.1 0.9 1.0 4 5 8 4 2 4 4.4 5.2 6.9 4.2 1.8 4.2 11 9 7 5 5 11 12.2 9.4 6.0 5.3 4.5 11.5 20 57 21 25 3 22 22.2 59.4 18.1 26.3 2.7 22.9 54 25 80 60 100 58 60.0 26.0 69.0 63.2 90.1 60.4 0 2 1 0 0 1 0.0 2.2 0.5 0.0 0.0 1.7 4 6 10 0 6 1 18.2 6.9 4.9 0.0 3.0 1.7 5 4 19 2 16 2 22.7 4.4 9.3 7.4 7.9 3.4 4 29 48 8 48 11 18.2 31.9 23.5 29.6 23.8 19.0 9 50 126 17 132 43 40.9 54.9 61.8 63.0 65.3 74.1 < 0.001 1 1 2 0 3.1 0.3 1.2 0.0 7 14 5 0 21.9 3.7 2.9 0.0 5 30 11 2 15.6 7.9 6.4 11.1 6 105 33 4 18.8 27.6 19.2 21.2 13 231 121 12 40.6 60.6 70.3 66.7 < 0.014 1 3 0.2 1.9 17 10 3.8 6.5 37 11 8.2 7.1 128 20 28.4 13.0 267 110 59.3 71.4 < 0.001 4 % 0.7 Seldom No. 27 % 4.5 Use seat-belt Sometimes No. 48 % 7.9 Often No. 148 % 24.5 Always No. 377 % 62.4 < 0.001 P-value
Table 5 Citizens’ reported reasons for using and not using vehicle seat-belts in the interview study (n = 604) Variable Reasons for wearing seat-belt Avoiding fines and penalties Fear of injury Respecting law Importance of health Awareness of severity of injury Effectiveness of seat-belt Seat-belt wearing is a sensible practice Reasons for not wearing seat-belt Lack of awareness of risks Lack of awareness of regulations Not in the habit of wearing seat-belt It is uncomfortable and restricts movement Embarrassment Vehicle is not equipped with standard safety-belts It takes too much time to fasten Participants could choose more than 1 option.
No. 379 329 299 245 184 87 82 311 244 244 183 164 113 70
% 62.7 54.4 49.5 40.5 30.4 14.4 13.5 51.4 40.4 40.4 30.3 27.1 18.7 11.5
seat-belt use, we suggest that law enforcement accompanied by more public education should be seen as priority.
Acknowledgements This paper originated from the PhD thesis of the first investigator at the Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Islamic Republic of Iran. The authors are grateful to the Applied Research Department of Tehran Traffic Police, and to the observers, interviewers and all the participants who helped us in this work during the hot summer days of Tehran. Funding: None. Competing interests: None declared.
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املجلد العرشون العدد الثامن
املجلة الصحية لرشق املتوسط
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