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Topics in Minority Health Safety-Belt Use and Motor-Vehicle-Related Injuries -- Navajo Nation, 1988-1991

Injuries are the second leading cause of death among American Indians and Alaskan Natives; during 1986-1988, injuries accounted for 22% of all deaths (1). The risk for motor-vehicle-related injury deaths is nearly threefold higher among American Indians and Alaskan Natives than among the total U.S. population (age-adjusted death rates: 57.5 per 100,000 versus 19.5 per 100,000) (1-3). For residents of many rural, western, Indian reservations, age-adjusted motor-vehicle-related death rates are substantially higher; in particular, the rates for Navajos * are fivefold greater than for the total U.S. population (97.9 per 100,000 versus 19.5 per 100,000) (1) and almost three times the rate for all New Mexico residents (35.2 per 100,000) (4). To increase safety-belt use by front-seat occupants and thereby reduce motor-vehicle-related injuries, the Navajo Area Indian Health Service (IHS) Office of Environmental Health and Engineering, the Navajo Department of Highway Safety, and the Navajo Nation implemented a primary enforcement ** safety-belt use law and educational campaign. This report summarizes results of their effort.

The initial focus of the Navajo safety-belt campaign was to build support among tribal leaders for passage of a safety-belt use law *** for the Navajo Nation. In July 1988, the Navajo Nation enacted a primary enforcement safety-belt use law. The campaign then initiated an intensive public information program about the new law and the benefits of safety-belt use. Enforcement (i.e., issuing citations for nonuse of safety belts), the last major component of the campaign, was initiated by the Navajo Nation Department of Law Enforcement in January 1990, with rigorous widespread enforcement in place by June 1990.

In June 1988, trained IHS staff conducted baseline observational surveys of safety-belt use by front-seat occupants at sites throughout the Navajo Nation; the surveys continued on a monthly basis by IHS and Navajo Nation Department of Highway Safety staff and are ongoing. Safety-belt use in the Navajo Nation from 1983 through 1987 was estimated from observational surveys conducted by IHS staff in 1985. Information on motor-vehicle- related injuries was obtained from an E-coded (International Classification of Diseases, Ninth Revision, Clinical Modification, external cause-of-injury codes) hospital discharge data base maintained by the IHS. All American Indian residents of the Navajo Nation are eligible for medical care from the IHS. Only motor-vehicle-related traffic injuries involving either the driver or an occupant (E810-E819) were selected.

From June 1988 through September 1991, the prevalence of safety-belt use on the Navajo Nation increased from 14% to 60% (Figure 1). In June 1988 before the law was passed, rates of safety-belt use were low for males and females (13.8% and 14.4%, respectively); sex-specific data for subsequent periods were not complete. During the baseline survey, a total of 6109 vehicles were observed; 58% of these were driven by males. Most (56%) vehicles were pickup trucks; 678 persons were observed riding in the back of pickup trucks.

From 1988 through 1990, motor-vehicle-related injury hospitalization rates for Navajo Indians decreased 28.5%, from 196.3 per 100,000 to 140.3 per 100,000 (Figure 1). During this period, rates for injury hospitalization decreased more for females than for males (46% versus 14%) (Table 1).

Reported by: N Bill, MPH, G Buonviri, MPH, P Bohan, MS, Office of Environmental Health and Engineering, Navajo Area Indian Health Svc, Window Rock, Arizona. L Garnanez, Navajo Dept of Highway Safety, Navajo Div of Public Safety, Navajo Nation. Program Development and Implementation Br, National Center for Injury Prevention and Control, CDC.

Editorial Note

Editorial Note: Safety-belt use in the United States increased from 11% in 1982 to 59% in 1991, reflecting the passage and enforcement of mandatory safety-belt use legislation (5). The National Highway Traffic Safety Administration estimates that among front-seat passenger-vehicle occupants aged greater than 4 years safety-belt use prevented 4800 deaths and 125,000 moderate to critical injuries in 1990 (6). The trends in this report suggest efforts to increase safety-belt use in targeted high-risk populations can decrease the risk for motor-vehicle-related injuries.

American Indians and Alaskan Natives are at increased risk for motor-vehicle-related deaths and injuries for at least three reasons. First, because many American Indians and Alaskan Natives live in rural areas, their access to advanced emergency medical care may be limited when a crash occurs, and as a consequence, treatment for injuries may be delayed. Second, American Indians and Alaskan Natives may travel more on isolated two-lane highways and ride unprotected (e.g., unrestrained) in the back of open pickup trucks (3), placing them at higher risk for injury if a crash occurs. Third, this population is younger than the total U.S. population (median age: 23 years versus 30 years); young persons are at higher risk for injury because of risk-taking behaviors, such as drinking and driving and not wearing safety belts. Such risk factors also contributed to high death rates among Navajo residents: from 1986 to 1988, the Navajo Nation had the second highest motor-vehicle-related death rate of all 12 IHS geographic areas (1). In addition, because alcohol is not legally available in the Navajo Nation, those residents who drink may drive long distances while impaired.

The findings in this report indicated that the decline in motor-vehicle-related injury rates was greater for Navajo females than males. Potential explanations for this difference are that 1) more Navajo women than men may have begun wearing safety belts after the law was passed; 2) males may spend more time as motor-vehicle occupants than females; and 3) males who do not use safety-belts engage in risky driving behavior more often than males who do use safety belts (7). Special efforts may be needed to target high-risk behavior, such as impaired driving and riding unprotected in the back of pickup trucks.

Although the decline in motor-vehicle-related injuries coincided temporally with increased safety-belt use in the Navajo Nation, a clear causal relation could not be established. Other factors that may have contributed include fewer persons driving while under the influence of alcohol, use of safer motor vehicles, corrections of roadway hazards, and occurrence of fewer crashes.

The Navajo Nation safety-belt use law and campaign is an example of a successful comprehensive program to increase safety-belt use and reduce motor-vehicle-related injury. The strategy used by the Navajo Nation -- integrating public education and strict enforcement of a safety-belt law -- has been implemented with success elsewhere to increase safety-belt use (5). As of August 1992, 41 states have passed mandatory safety-belt use laws; only 13 of 510 American Indian tribes have implemented safety-belt use laws on federal reservations. The enactment and enforcement of a primary enforcement safety-belt use law for the Navajo Nation is assisting in reducing the disproportionate impact of motor-vehicle- related injury and death among the Navajo population.


  1. Indian Health Service. Regional differences in Indian health, 1991. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, 1991.

  2. Indian Health Service. Injuries among American Indians, Alaska Natives, 1990. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, Indian Health Service, 1990.

  3. Baker SP, O'Neill B, Ginsburg MJ, Li G. The injury fact book. 2nd ed. New York: Oxford University Press, 1992.

  4. National Highway Traffic Safety Administration. Fatal Accident Reporting System, 1989: a review of information on fatal traffic crashes in the United States in 1989. Washington, DC: US Department of Transportation, National Highway Traffic Safety Administration, 1991; DOT publication no. HS-807-693.

  5. CDC. Increased safety-belt use -- United States, 1991. MMWR 1992;41:421-3.

  6. National Highway Traffic Safety Administration. Occupant protection facts. Washington, DC: US Department of Transportation, National Highway Traffic Safety Administration, 1991.

  7. CDC. Safety-belt use among drivers involved in alcohol-related fatal motor-vehicle crashes -- United States, 1982-1989. MMWR 1991;40:397-400.

    • The Navajo Nation is one of the largest American Indian tribes in the United States (estimated 1990 population: 191,000) and territorially includes parts of Arizona, New Mexico, and Utah, with a land size comparable to the state of West Virginia. ** Primary enforcement of safety-belt use laws permit law enforcement officers to stop drivers for a safety-belt use violation alone, whereas secondary enforcement laws require that a vehicle must first be stopped for some other traffic violation. *** Federally recognized Indian tribes and their reservations are considered sovereign nations, where some state motor-vehicle codes such as mandatory occupant-restraint laws often do not apply.

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