Journal of Safety Research 53 (2015) 103–106

Contents lists available at ScienceDirect

Journal of Safety Research

journal homepage: www.elsevier.com/locate/jsr

Special report from the CDC

Predictors of rear seat belt use among U.S. adults, 2012☆

Geeta Bhat, a,

⁎ Laurie Beck, a Gwen Bergen, a Marcie-jo Kresnow b

a Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA 30096, USA b Division of Analysis, Research and Practice Integration, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA 30096, USA

The Journal of Safety Research has partnered with the Office of the Associate Director for Science, Division of Unintentional Injury Prevention in the National Center for Injury Prevention &

Control atthe Centers for Disease Control and Prevention (CDC) inAtlanta, Georgia, USA,to briefly report on some ofthe latest findings in the research community. This reportis the 36th in

a series of CDC articles.

article info abstract

Article history: Introduction: Seat belt use reduces the risk of injuries and fatalities among motor vehicle occupants in a crash, but

Received 24 March 2015 belt use in rear seating positions is consistently lower than front seating positions. Knowledge is limited

Accepted 24 March 2015 concerning factors associated with seat belt use among adult rear seat passengers. Methods: Data from the

Available online 8 April 2015 2012 ConsumerStyles survey were used to calculate weighted percentages of self-reported rear seat belt use by

demographic characteristics and type of rear seat belt use enforcement. Multivariable regression was used to

Keywords: calculate prevalence ratios for rear seat belt use, adjusting for person-, household- and geographic-level demo- Safety graphic variables as well as for type of seat belt law in place in the state. Results: Rear seat belt use varied by Transportation

age, race, geographic region, metropolitan status, and type of enforcement. Multivariable regression showed Primary law

Motor vehicle that respondents living in states with primary (Adjusted Prevalence Ratio (APR): 1.23) and secondary

Injury (APR: 1.11) rear seat belt use enforcement laws were significantly more likely to report always wearing a seat

belt in the rear seat compared with those living in a state with no rear seat belt use enforcement law. Conclusions

and practical applications: Several factors were associated with self-reported seat belt use in rear seating positions.

Evidence suggests that primary enforcement covering all seating positions is an effective intervention that can be

employed to increase seat belt use and in turn prevent motor vehicle injuries to rear-seated occupants.

© 2015 National Safety Council and Elsevier Ltd. All rights reserved.

1. Introduction

Observational studies report that the use of seat belts in rear seating positions was at least 10 percentage points lower than front seat belt use

every year from 2009 to 2012 (Pickrell, 2014). Among adult non-drivers (i.e., front-right seat passengers and rear seat passengers), those in rear

seats represented 26% of deaths in 2012 (unpublished data, FARS data query 10/29/2014). Among rear seat occupants, seat belt use can reduce

the risk for death by 60% (Zhu, Cummings, & Chu, 2007). Additionally, multiple studies have documented the increased risk of death (Bose,

Arregui-Dalmases, Sanchez-Molina, Velazquez-Ameijide, & Crandall, 2013; Mayrose et al., 2005) or serious injury (Ichikawa, Nakahara, & Wakai,

2002) for restrained occupants when unrestrained rear seat occupants are also in the vehicle. For example, in fatal frontal crashes in the United

States, the odds of driver death in the presence of unrestrained rear-seat occupants are more than double those in which rear-seat occupants are

restrained (Bose et al., 2013).

Much of the existing literature on predictors of adult seat belt use focuses on seat belt wearing generally (without specifying a seating position) or

relies on data sources (e.g., observational) that are limited in the breadth of individual-level data that can be collected (Beck, Shults, Mack, & Ryan,

2007; Pickrell, 2014; Strine et al., 2010). Therefore, the purpose of this study was to improve our understanding of predictors of seat belt use among

adult rear seat passengers.

☆ Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

⁎ Corresponding author at: Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 4770 Buford

Highway NE, MS-F62, Atlanta, GA 30096, USA.

http://dx.doi.org/10.1016/j.jsr.2015.03.011

0022-4375/© 2015 National Safety Council and Elsevier Ltd. All rights reserved.
104 G. Bhat et al. / Journal of Safety Research 53 (2015) 103–106

2. Methods

The data used in this study came from the summer wave of Porter Novelli's1 2012 ConsumerStyles database (Summer ConsumerStyles, 2012

Survey, 2012). The ConsumerStyles database is built annually from a series of web-based surveys that gather information about Americans, including

information about their health-related attitudes and behaviors.

The Summer ConsumerStyles survey was fielded from June 19–July 3, 2012 to 4754 adults (18 years or older) and a supplemental sample of 1648

adults with children aged 12–17 who previously completed the spring wave and belong to GfK's KnowledgePanel2

. A total of 4170 surveys were

returned, for a response rate of 65%.

The data were weighted to match the U.S. Current Population Survey proportions for sex, age, household income, race/ethnicity, household size,

education level, census region, metropolitan status, and whether or not a respondent had internet access prior to joining the panel. Weights were

then scaled back to reflect the sample size of the study (ConsumerStyles, 2012 Methodology, 2012).

The CDC licensed the results of the 2012 Summer ConsumerStyles survey post-collection from Porter Novelli, and analysis of these data was

exempt from institutional review board approval because personal identifiers were not included in the data file.

Survey respondents were asked how often they wear seat belts when riding in the back seat of a car, truck, van, or sport utility vehicle. We combined response categories of ‘nearly always,’ ‘sometimes,’ ‘seldom,’ and ‘never,’ into a single ‘less than always’ category and compared with ‘always’

for the purposes of our analyses. Respondents who reported never riding in the back seat were excluded from all analyses (n = 217). For each state in

2012, we used data from the Insurance Institute for Highway Safety (IIHS) to determine whether there was a rear seat belt law for adults, and if there

was a law, whether it was a primary (allows law enforcement to ticket a driver or passenger for not wearing a seat belt without any other traffic offense taking place) or secondary law (law enforcement may only ticket for not wearing a seat belt when there is another citable traffic violation).

Crude analyses examined associations between demographic characteristics and type of rear seat belt use enforcement with always wearing a

seat belt when riding in the rear seat. Demographic characteristics examined included gender, age, race/ethnicity (categorized mutually exclusively

as white, black, Hispanic, or other [American Indian/Alaska Native, Asian, Native Hawaiian or Pacific Islander, or multiracial]), education, marital status, household income, census region, and metropolitan status of the respondent's residence (categorized as metropolitan or non-metropolitan using

the U.S. Census Bureau standards [Zients, 2013]). Type of rear seat belt use enforcement was categorized as primary law, secondary law, or no law.

Weighted percentages, 95% confidence intervals (CI), and chi-square testfor categorical variables or Cochran–Armitage trend testfor categorical variables that had potential linear trend were calculated for seat belt use in the rear seat. Multivariable regression was performed using the log-binomial

model with the Log link function to calculate the prevalence ratios and 95% CIs for always wearing a seat belt when riding in the rear seat, adjusting

for demographic variables as well as type of rear seat belt use enforcement. Results with p-value b 0.05 were considered statistically significant. All

analyses were completed using Statistical Analysis Software (SAS) version 9.3 (SAS Institute, Inc., Cary, North Carolina).

3. Results

In 2012, 62% of respondents reported always wearing a seat belt when riding in the rear seat (Table 1). Respondents living in the West were

significantly more likely to report always wearing a seat belt (75%) compared with those living in the Northeast, Midwest, and South (52%, 58%,

60%, respectively [p b 0.01]). In 2012, 16 states and the District of Columbia had primary rear seat belt use enforcement, 10 states had secondary

rear seat belt use enforcement, and 24 states had no rear seat belt use enforcement. Respondents living in states with a primary seat belt law covering

rear seat occupants were significantly more likely to report always wearing a seat belt (71%) compared with those living in states with secondary

(62%) or no law (54%) for rear seat passengers (p b 0.01). Respondents in secondary law states were also significantly more likely to report seat

belt use compared with those living in states with no law (p b 0.05).

When all predictors were included in the multivariable model (Table 2), respondents aged 18–24 years were 9% more likely to report always

wearing a seat belt than those aged 25–44 (p b 0.05) when controlling for other variables. Respondents aged 45–64 years and 65 years and over

were 14% and 16% more likely, respectively, to report always wearing a seat belt in the rear seat than those aged 25–44 years. Respondents living

in metropolitan areas were 11% more likely to report always wearing a seat belt in the rear seat, compared with those living in non-metropolitan

areas. Respondents living in the West were 25% more likely to report always wearing a seat belt in the rear seat than those living in the Midwest

or Northeast and almost 20% more likely to report always wearing a seat belt than those living in the South. Respondents in states with primary

and secondary rear seat belt use laws were 23% and 11% more likely, respectively, to report always wearing a seat belt in the rear seat than those

living in a state with no rear seat belt use law (Table 2).

4. Discussion

We found that only 62% of adults reported always wearing their seat belts when riding in a rear seat. Although studies have shown restraint use in

both front and rear seating positions have increased over time, belt use in rear seats remains lower than in other seating positions (Boyle & Lampkin,

2008; Pickrell, 2014; Trowbridge & Kent, 2009). For example, observed front seat belt use was 86% in 2012 compared with 75% for rear seat occupants

aged 8 years and older (Pickrell, 2014). The lower use may be because of perceptions that the rear seatis safer compared with other seating positions.

While the rear seat was previously reported safer than the front seat in older model vehicles (Mayrose & Priya, 2008; Smith & Cummings, 2004),

several vehicle safety improvements introduced since 1997 have changed the relative protection for rear versus front seating positions, making

the front seat safer than the rear seat for belted occupants over 15 years of age (Bilston, Du, & Brown, 2010). However, restrained children aged

9–15 are still at lower risk for serious injury or fatality when sitting in the rear seat (Bilston et al., 2010).

This study found that primary rear seat belt use laws are strongly associated with rear seat belt use, echoing results from studies of overall seat belt

use and primary law enforcement (Beck & Shults, 2009; Beck et al., 2007). In 2012, only 40% of the U.S. adult population was covered by a primary

rear seat belt use enforcement law (U.S. Census Bureau). Our crude analysis showed that presence of a primary law was significantly associated with

1 Porter Novelli Public Services is a public relations firm with offices in Washington, DC. 2 GfK's KnowledgePanel members are randomly recruited using probability-based sampling and include respondents regardless of whether or not they have landline phones or Internet

access. If needed, households are provided with a laptop computer and access to the Internet. The panel is continuously replenished and maintains approximately 50,000 panelists.
G. Bhat et al. / Journal of Safety Research 53 (2015) 103–106 105

Table 1

Demographic characteristics by rear belt use, n = 3953, Summer ConsumerStyles survey, 2012.

Trait Always wears a seat belt when riding in rear seat

Level Total Unweighted Count Unweighted Count Weighted % 95% CI p-Value

Gender

Male

Female

Age (years)

18–24

25–44

45–64

65+

1804

2149

360

1179

1651

763

1122

1408

232

700

1095

503

60.0

62.9

62.2

55.7

64.3

67.1

56.9–63.1

60.1–65.8

55.8–68.7

51.9–59.6

61.0–67.5

62.7–71.5

0.17

b0.01a

Race/ethnicity

White

Black

Hispanic

Other

Education

High school or less

Some college

College grad or higher

2928

379

417

229

1250

1264

1439

1902

213

277

138

778

819

933

63.1

56.4

63.2

51.8

60.4

63.5

61.3

60.8–65.5

49.5–63.3

57.0–69.5

42.5–61.0

56.8–64.0

60.0–67.0

57.7–64.8

0.04

0.46a

Marital status

Married

Not married

Household income

Under $25 k

$25 k to b $50 k

$50 k to b $75 k

$75 k+

2361

1592

617

889

798

1649

1547

983

375

555

512

1088

63.1

59.8

57.9

61.8

58.7

64.6

60.4–65.8

56.5–63.0

52.4–63.3

57.5–66.1

54.0–63.4

61.5–67.7

0.12

0.08a

Census region

Northeast

Midwest

South

West

729

978

1345

901

398

584

838

710

51.8

57.7

59.7

75.2

46.9–56.8

53.4–62.0

56.2–63.2

71.1–79.2

b0.01

Metropolitan status

Metropolitan

Non-metropolitan

3362

591

2179

351

62.5

56.5

60.3–64.8

51.1–61.8

0.04

Rear seat law

Primary law

Secondary law

No law

Total

1545

473

1935

3953

1135

300

1095

2530

71.0

62.0

53.7

61.6

67.8–74.2

56.0–68.0

50.7–56.7

59.5–63.6

b0.01

b0.01

a p-Values accompanied with an asterisk indicate Cochran–Armitage trend test. Otherwise, p-values indicate Chi square test.

higher rear seat belt use when compared with states that have secondary law enforcement, but the significance disappeared when we controlled for

other variables.

We also saw that rear seat belt use varies by both region and metropolitan status, with occupants in the Western or metropolitan areas reporting

rear seat belt use in greater proportions than all other regions or nonmetropolitan areas. The difference by region may partly be due to more Western

states having primary laws. Nearly 70% of the population living in the Western states has a primary law in effect for rear seating positions; whereas,

the majority of the population (68%) in states of all other regions has a secondary or no law in effect. These findings were consistent with Strine et al.'s

findings related to higher general belt use in Western and metropolitan areas (Strine et al., 2010).

Although many predictors of rear seat belt use found in our study are consistent with previous research on general or front seating position seat

belt use, some differences were observed. First, although males are widely reported to have lower seat belt use rates than females (Beck et al., 2007;

Boyle & Lampkin, 2008), our study found no statistically significant gender difference for seat belt use among rear seat passengers, as did Pickrell

(2014). Second, seat belt use is generally shown to increase with increasing age (Beck et al., 2007; Boyle & Lampkin, 2008; Pickrell, 2014). However,

we found that young adults (18–24 years) have higher rates of rear seat belt use than those who are 25–44 years of age when adjusting for other

variables. Reasons why young adults have higher rates of rear seat belt use needs further exploration.

Our study has limitations. First, this dataset may not be representative of the U.S. population because the sampling approaches used were not random; however, Pollard's research comparing consumer panel data with national population probability sampling data shows support for the use of a

consumer panel survey such as ConsumerStyles in public health research because response values,trends over time, and demographic breakdowns for

the two sampling types are in close agreement (Pollard, 2007). Second, seat belt use was self-reported and may be subject to social desirability bias.

However, the use of self-reported data permitted the collection and analysis of important individual-level characteristics that are not otherwise

available in observational studies.

Primary enforcement laws for rear seating positions had a strong statistical association with always wearing a seat belt when riding in a rear seat.

These laws may also compel increased use of seat belts among demographic groups that generally report lower levels of seat belt use (Beck et al.,

2007). Evidence therefore suggests that primary enforcement legislation covering all seating positions is an effective intervention that can be

employed to increase seat belt use and decrease risk for motor vehicle-related injuries and fatalities to rear-seat occupants.
106 G. Bhat et al. / Journal of Safety Research 53 (2015) 103–106

Table 2

Prevalence ratios and 95% CI for always wearing a seat belt when riding in the rear seat, Summer ConsumerStyles survey, 2012.

Trait Crude Adjusteda

Level Prevalence ratio 95% CI lower limit 95% CI upper limit Adjusted prevalence ratio 95% CI Lower limit 95% CI upper limit

Gender

Male

Female

1.00

1.05

–

1.00

–

1.10

1.00

1.04

–

1.00

–

1.09

Age (years)

18–24

25–44

45–64

65+

1.12

1.00

1.15

1.20

1.03

–

1.08

1.12

1.21

–

1.23

1.29

1.09

1.00

1.14

1.16

1.00

–

1.08

1.09

1.18

–

1.21

1.24

Race/ethnicity

White

Black

Hispanic

Other

1.00

0.89

1.00

0.82

–

0.82

0.94

0.73

–

0.97

1.07

0.92

1.00

0.95

0.97

0.80

–

0.87

0.91

0.71

–

1.03

1.03

0.89

Income

Under $25 k

$25 k to b$50 k

$50 k to b$75 k

$75 k+

1.00

1.07

1.01

1.12

–

0.98

0.93

1.04

–

1.16

1.10

1.20

1.00

1.01

0.95

0.99

–

0.94

0.89

0.92

–

1.10

1.08

1.05

Education

High school or less

Some college

College graduate or higher

1.00

1.05

1.00

–

0.99

0.96

–

1.11

1.08

1.00

1.03

0.99

–

0.97

0.92

–

1.08

1.05

Marital status

Married

Not married

1.00

0.95

–

0.90

–

1.00

1.00

0.98

–

0.93

–

1.03

Metropolitan status

Non-metropolitan

Metropolitan

1.00

1.11

–

1.03

–

1.19

1.00

1.11 1.03 1.19

Region

Northeast

Midwest

South

West

0.90

1.00

1.03

1.30

0.82

–

0.96

1.22

0.98

–

1.11

1.40

0.96

1.00

1.05

1.25

0.87

–

0.98

1.16

1.06

–

1.13

1.33

Rear seat law

Primary law

Secondary law

No law

1.32

1.15

1.00

1.25

1.07

–

1.39

1.25

–

1.23

1.11

1.00

1.16

1.02

–

1.30

1.20

–

a The adjusted model controlled for all variables presented in the crude modeling.

References

Beck, L., & Shults, R. (2009). Seat belt use in states and territories with primary and secondary laws — United States, 2006. Journal of Safety Research, 40(6), 469–472.

Beck, L., Shults, R., Mack, K., & Ryan, G. (2007). Comparison of factors associated with safety belt use in states with and without primary enforcement laws. American Journal of Public

Health, 97(9), 1619–1624.

Bilston, L., Du, W., & Brown, J. (2010). A matched-cohort analysis of belted front and rear seat occupants in newer and older model vehicles shows that gains in front occupant safety have

outpaced gains for rear seat occupants. Accident Analysis and Prevention, 42(6), 1974–1977.

Bose, D., Arregui-Dalmases, C., Sanchez-Molina, D., Velazquez-Ameijide, J., & Crandall, J. (2013). Increased risk of driver fatality due to unrestrained rear-seat passengers in severe frontal

crashes. Accident Analysis and Prevention, 53, 100–104.

Boyle, J., & Lampkin, C. (2008). 2007 Motor Vehicle Occupant Safety Survey Volume 2 Seat Belt Report. (Report No. DOT HS 810 975). Washington, DC: National Highway Traffic Safety

Administration.

U.S. Census Bureau (d). Source: state characteristics: vintage 2012. http://www.census.gov/popest/data/state/asrh/2012/ (Date accessed Feb 2015).

ConsumerStyles 2012 Methodology (2012). Porter Novelli public services. Washington, DC: Deanne Weber.

Fatality Analysis Reporting System (d). Source: National Highway Traffic Safety Administration. http://www.nhtsa.gov/FARS (Date accessed Oct 2014).

Ichikawa, M., Nakahara, S., & Wakai, S. (2002). Mortality of front-seat occupants attributable to unbelted rear-seat passengers in car crashes. Lancet, 359(9300), 43–44.

Mayrose, J., Jehle, D., Hayes, M., Tinnesz, D., Piazza, G., & Wilding, G. (2005). Influence of the unbelted rear-seat passenger on driver mortality: “The Backseat Bullet.”. Academic Emergency
 

Medicine, 12(2), 130–134.

Mayrose, J., & Priya, A. (2008). The safest seat: effect of seating position on occupant mortality. Journal of Safety Research, 39(4), 433–436.

Pickrell, T. (2014). Occupant restraint use in 2012: results from the National Occupant Protection use Survey Controlled Intersection Study (Report No. DOT HS 811 872). Washington, DC:

National Highway Traffic Safety Administration.

Pollard, W. (2007). Evaluation of consumer panel survey data for public health communication planning: AN analysis of annual survey data from 1995–2006. Proceedings of the Section on

Health Policy Statistics (pp. 1528–1533). Salt Lake City, UT: American Statistical Association.

Smith, K., & Cummings, P. (2004). Passenger seating position and the risk of passenger death or injury in traffic crashes. Accident Analysis and Prevention, 36(2), 257–260.

Strine, T., Beck, L., Bolen, J., Okoro, C., Dhingra, S., & Balluz, L. (2010). Geographic and sociodemographic variation in self-reported seat belt use in the United States. Accident Analysis and

Prevention, 42(4), 1066–1071.

Summer ConsumerStyles 2012 Survey. (2012). Unpublished raw data. Porter Novelli Public Services. Washington, DC: Deanne Weber.

Trowbridge, M., & Kent, R. (2009). Rear-seat motor vehicle travel in the U.S.: using national data to describe a population at risk. American Journal of Preventive Medicine, 37(4), 321–324.

Zhu, M., Cummings, P., & Chu, H. (2007). Association of rear safety belt use with death in a traffic crash: a matched cohort study. Injury Prevention, 13(3), 183–185.

Zients, J. (2013). Revised delineations of metropolitan statistical areas, micropolitan statistical areas, and combined statistical areas, and guidance on uses of the delineations of these areas (OMB

Bulletin No. 13-01). Washington, DC: Executive Office of the President, Office of Management and Budget.