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Use of Safety Belts -- Madrid, Spain, 1994

An estimated 300,000 persons die and 10-15 million persons are injured each year in traffic crashes throughout the world (1). In Spain, during 1993, motor-vehicle crashes accounted for 6378 deaths (16 per 100,000 population) and were the leading cause of death for persons aged 1-44 years and the leading cause of years of potential life lost (2). Safety belts are 40%-70% effective in preventing severe injuries and deaths associated with motor-vehicle crashes (3). In April 1975, the Traffic Safety Administration of Spain implemented a mandatory safety-belt-use law for persons who were front-seat passengers traveling outside city limits (i.e., interurban traffic). On June 15, 1992, the law was expanded to include all front-seat passengers traveling in vehicles in the city limits and passengers in the back seats of vehicles with manufacturer-installed safety belts (4). In September 1994, the Ministry of Health of Spain, in collaboration with the Traffic Safety Administration, conducted surveys to assess the impact of the expanded law. This report summarizes findings of this assessment in Madrid, including the first direct observation survey of safety-belt use by front-seat occupants and a telephone sample survey of knowledge, attitudes, and behaviors related to motor-vehicle use. Observational Survey

The observational survey was conducted at five city intersections and five intersections at principal gates leading out of the city. At each site, two persons began observations by selecting the second vehicle in a stopped position and observing three consecutive vehicles per traffic light cycle. At each site, approximately 400 vehicles were observed, including approximately 100 observations (50 in each direction) during each of four time periods (weekday 8-10 a.m., weekday 7-9 p.m., weekend 8-10 a.m., and weekend 7-9 p.m.). Each front-seat occupant was counted separately. Vehicles exempted from the law (taxis and public service vehicles) were excluded.

Of the 4069 total observations, 2381 (58.5% {95% confidence interval (CI)=57.0%-60.1%) of front-seat occupants were using safety belts Table_1. The overall prevalence of use at the interurban city gates was 67.2% (range: 58.2%-80.0%) while the prevalence within the city was 50.1% (range: 43.5%-59.1%) (prevalence ratio {PR}=1.3; p less than 0.05). The prevalence of safety-belt use was greater among women than men (61.9% and 56.7% {PR=1.1; p less than 0.05}) but similar when compared by intersection, day of week, hour of day, and seat position of vehicle occupant (5,6). Telephone Survey

The Madrid city residential telephone directory was used to obtain a random sample of eligible potential respondents. Interviewers obtained information from respondents aged greater than or equal to 18 years about the number of persons aged greater than or equal to 18 years at home.

Of 1063 phone numbers called to identify eligible households, 294 (27.7%) could not be contacted (no one answered or the line was busy), and 185 were excluded (because either the phone number was commercial {37}, or no one aged greater than or equal to 18 years was in the home at the time of the call, or respondents never traveled by vehicle {185}). Categories of safety-belt use included always, almost always, sometimes, seldom, and never. Those who reported always wearing safety belts were considered users for the analysis (7).

Of the 584 eligible persons, 433 (74.1%) completed the interview (respondents); 232 (53.6%) were women. Follow-up calls were made to the 151 nonrespondents to obtain demographic information; of these, 91 (60.3%) agreed to an interview. The distribution by sex was similar among respondents and nonrespondents; however, a higher proportion of nonrespondents than respondents were aged greater than or equal to 60 years (37% compared with 21%, p less than 0.05).

The prevalence of self-reported safety-belt use in interurban areas was 94.0% (95% CI=91.8%-96.2%); the prevalence in the city was 64.0% (95% CI=59.5%-68.5%) Table_2. Age and sex were not associated with safety-belt use during interurban or city travel. Characteristics associated with increased city safety-belt use included history of motor-vehicle collision (PR=1.2 {95% CI=1.0- 1.5}) and positive opinions of effectiveness. Risk factors associated with safety-belt nonuse in the city included history of previous motor-vehicle fine (e.g., speeding or running stop signals) (PR=3.7 {95% CI=1.3-10.5}) and negative opinion of the effectiveness of safety belts (PR=1.8 {95% CI=1.4-2.3}). The prevalence of safety-belt use in interurban areas was higher among respondents who reported no history of fines, who denied driving under the influence of alcohol at least once during the preceding month, and who had a positive opinion of the effectiveness of safety belts. Reported by: P Godoy, J Castell, EF Peiro, D Herrera, J Rullan, Field Epidemiology Training Program, National Center for Epidemiology, Carlos III Institute of Health, Ministry of Health and Consumer Affairs, Madrid; A Patricia, C Ibanez, M Marin, A Molejon, C Plitt, L Relano, C Ruiz, C Sanz, J Torcal, O Vazquez, F Yanez, autonomous community health depts, Spain. Field Epidemiology Training Program, Div of Field Svcs, Epidemiology Program Office; Div of Unintentional Injury Prevention, National Center for Injury Prevention and Control, CDC.

Editorial Note

Editorial Note: The findings from both the direct observational and the telephone surveys described in this report suggest that persons in Madrid are less likely to use safety belts while in vehicles traveling within the city and more likely to use safety belts in interurban areas. Potential explanations for this difference are 1) the first law enacted in 1975 applied only to travel in areas outside of the city, and the intent of the expanded law of 1992 has neither been understood nor accepted by many persons; 2) a substantial proportion of persons are unaware of the risks for collision associated with the shorter distances traveled within the city; and 3) efforts to enforce the expanded law have been more vigorous in interurban areas.

Direct observational surveys, such as that described in this report, provide valid estimates of safety-belt use. The telephone survey supplemented the observational survey by assessing knowledge, attitudes, and behaviors regarding safety-belt use. However, previous reports indicate that telephone surveys overestimate the use of safety belts, compared with estimates by observational surveys (5,6). In the United States, the National Highway Traffic Safety Administration has recommended the periodic use of observational probability sample surveys at the same intersections to assess changes in safety-belt use. *

In 1992, the motor-vehicle collision fatality rate in Spain (4.8 motor-vehicle deaths per 100 million kilometers {62.5 million miles} traveled) ranked second in Europe after Portugal (9.0), and was substantially higher than that in other countries, including the United Kingdom (1.1), Holland (1.3), Germany (1.9), France (2.0), and the United States (1.1) (8). Factors associated with the higher rate in Spain may include the quadrupling in the estimated number of motor vehicles operating since 1970; road conditions -- which are being rapidly improved but lag in comparison to some other industrialized countries in Europe; and the condition of currently operating vehicles (i.e., 38% of vehicles in use are greater than 10 years old).

Findings in this study indicated that a positive attitude toward safety-belt effectiveness was most strongly associated with safety-belt use, both for city and interurban travel. In other countries, safety-belt use has increased following intense periodic campaigns combining public education about the benefits of safety-belt use and enforcement of safety-belt-use laws (9). In Spain, the Ministry of Health in collaboration with the Traffic Safety Administration will use these results in planning education programs to improve traffic safety and other projects to increase safety-belt use.


  1. Ross A, Baguley C, Hills B, McDonald M, Silcock D. Towards safer roads in developing countries: a guide for planners and engineers. Crowthorne, England: Transport and Road Research Laboratory, 1991.

  2. Traffic Safety Administration. Accidents 1993 {Spanish}. In: Annual Bulletin of the Traffic Safety Administration. Madrid, Spain: Ministry of Justice and Interior, 1993.

  3. Chorba TL. Assessing technologies for preventing injuries in motor vehicle crashes. Int J Technol Assess Health Care 1991;7:296-

  4. Royal Decree 13, January 17, 1992. General regulations on vehicle traffic. State official bulletin. January 31, 1992 (no. 27).

  5. CDC. Use of seat belts -- DeKalb County, Georgia, 1986. MMWR 1987;36:433-7.

  6. CDC. Driver safety-belt use -- Budapest, Hungary, 1993. MMWR 1993;42;939-41.

  7. Streff FM, Wagenaar AC. Are there really shortcuts? Estimating seat belt use with self-report measures. Accid Anal Prev 1989;21:509-16.

  8. International Road Federation. International Road Statistics, 1989-1993. Geneva, Switzerland: International Road Federation, 1994.

  9. Dessault C. Seat belt use: the Quebec experience. In: Proceedings of the National Leadership Conference on Increasing Safety Belt Use in the United States. Washington, DC: American Coalition for Traffic Safety, National Highway Traffic Safety Administration, 1991.

    • 57 FR 28899-904.

+------------------------------------------------------------------- -----+ |             | | Errata: Vol. 44, No. 8 | | ====================== | | SOURCE: MMWR 44(09);175 DATE: Mar 10, 1995 | |             | | In the article, "Use of Safety Belts -- Madrid, Spain, 1994," | | the first sentence on page 151 should read, "Of 1063 phone numbers | | called to identify eligible households, 294 (27.7%) could not be | | contacted (no one answered or the line was busy), and 185 were | | excluded (because the phone number was commercial, no one aged | | greater than or equal to 18 years was in the home at the time of | | the call, or respondents never traveled by vehicle)." | +------------------------------------------------------------------- -----+
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TABLE 1. Prevalence of safety-belt use, by selected characteristics of
front-seat occupants in an observational study -- Madrid, Spain, September
                                              Used safety belts
                     No.            ----------------------------------------
Characteristic     observed *        No.       %       PR +    (95% CI &)
  Women              1441            892     (61.9)    1.2     (1.1-1.4)
  Men                2628           1489     (56.7)

  Interurban @       2018           1356     (67.2)    2.1     (1.8-2.3)
  City               2049           1025     (50.0)

Day of week
  Weekend            2042           1209     (57.9)    1.0     (0.8-1.1)
  Weekday            1925           1072     (59.3)

Hour of day
  8-10 a.m.         2030            1172     (57.7)    0.9     (0.8-1.1)
  7- 9 p.m.         2037            1209     (59.3)

Seat position
  Driver             2897           1673     (57.7)    0.9     (0.8-1.0)
  Passenger          1170            708     (60.5)

Total                4069           2381     (58.5)
* Numbers may not add to totals because of missing information.
+ Prevalence ratio.
& Confidence interval.
@ Outside city limits.

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TABLE 2. Telephone survey of safety-belt use in city and interurban* areas, by selected
characteristics of respondents -- Madrid, Spain, September 1994
                                           City                             Interurban
                                ------------------------------    ------------------------------------
Characteristic   No. surveyed   No.    (%)    PR +  (95% CI &)     No.    (%)    PR +  (95% CI &)
  Women              232        151   (65.1)  1.0  ( 0.9- 1.2)    220  ( 94.8)  1.0  ( 1.0- 1.1)
  Men                201        126   (62.7)                      187  ( 93.0)

  of collisions
  Yes                 48         37   (80.4)  1.2  ( 1.0- 1.5) @   47  (100.0)
  No                 385        240   (62.0)                      360  ( 93.3)  1.1  ( 1.0- 1.1)

History of fines
  No                 415        274   (66.6)  3.7  ( 1.3-10.5) @  395  ( 95.2)  1.4  ( 1.0- 2.0) @
  Yes                 17          3   (16.7)                       12  ( 66.7)

Driving after
  drinking **
  No                 240        157   (65.4)  1.4  ( 0.9- 2.1)    229  ( 95.4)  1.2  ( 1.0- 1.5) @
  Yes                 23         11   (47.8)                       18  ( 78.2)

Excess speed
  No                 133         89   (66.9)  1.1  ( 0.9- 1.3)    128  ( 96.2)  1.0  ( 1.0- 1.1)
  Yes                135         82   (60.7)                      125  ( 92.6)

Opinion of safety-
  belt effectiveness
  Positive           320        231   (72.2)  1.8  ( 1.4- 2.3) @  385  ( 95.1)  1.3  ( 1.0- 1.6) @
  Negative           110         44   (40.0)                       16  ( 76.2)

Total                433        433   (64.0)       (59.5-68.5)    433  ( 94.0)       (91.8-96.2)
 * Outside city limits.
 + Prevalence ratio.
 & Confidence interval.
 @ p<0.05. 
** Driving under the influence of alcohol at least once during the preceding month.

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