Use of seat belts among public transport drivers in Tacna, Peru: Prevalence and risk factors.

INTRODUCTION: There are individuals who still refuse to wear seat belts, despite its effectiveness in reducing morbidity and mortality in road traffic accidents. We aimed to determine the prevalence and risk factors according to the use of seat belts among public transport drivers in Tacna, Peru.
METHODOLOGY: This analytical transversal study was carried out among public transport drivers (buses and taxis) in a Peruvian city. Questionnaires were used to evaluate the general and occupational characteristics and the use of seat belts (observed). Descriptive statistics and risk factors were obtained, these latter through generalized linear models.
RESULTS: Of the 460 drivers, 77% used their seat belts, with a difference in use depending on the type of public transport (p<0.001). In the multivariate model, the risk of not using the belt was associated with the following: older age (p<0.001), having complete studies (p<0.001), a higher level/category of driving license (3 categories had p<0.001), having a higher number of previous road traffic accidents (p = 0.011), and received medical attention in that accident (p<0.001), those who reported using a cell phone while driving (p = 0.005), if the co-driver's belt had 3 anchorage points (p<0.001), and working for > 5 hours that day (p = 0.002). However, male drivers and those who had their belt with 3 anchorage points had greater use (both p<0.001).
CONCLUSIONS: One in five drivers did not use a seat belt, and important characteristics of those who did not comply with this traffic law were evaluated to generate control and intervention measures.

Introduction

Road traffic crashes are a major public health problem, representing one of the most frequent causes of traumatic injuries and deaths worldwide [1, 2]. The seat belt is a safety feature, which reduces the risk of serious injury [3, 4] and death from road traffic crashes [5, 6]. Its use is mandatory for all vehicle occupants due to the legislation in force, and this is applied in several countries worldwide [1]. The prevalence of seat belt use varies to worldwide, as 48% [7], 73% [8], 58% [9], 82% [10], and 86–90% [11-13] were reported in Bosnia-Herzegovina, Korea, Iran, Singapore, and in the United States of America, respectively. On the contrary, in Latin American countries, the prevalence of 82% was reported in Ecuador [14], 36% in Colombia [15] and 38% in Mexico [16]; lower prevalence was observed among co-drivers [15, 16]. However, in another Peruvian city, a prevalence of 79% was reported among public transport drivers [17].

Several factors have been found to increase seat belt use, such as being in a city far from the capital, being female, driving a taxi [15], older age [10], and being more educated [7, 9, 11]. However, most of those studies were conducted using secondary databases [8, 10, 12, 13], through observations from outside the vehicles [7, 15–17] or through self-reports by the drivers [9, 11, 12, 14]. Therefore, it is necessary to conduct field research that directly observes their use and the most important influences, especially in low- and middle-income countries such as Peru [1]. The objective of our study was to determine the prevalence and risk factors to the use of seat belts among public transport drivers in Tacna, Peru.

Methodology

Study design, location and time

An observational, analytical, and cross-sectional study was conducted in the city of Tacna, located in southern Peru, during the years 2018 and 2019.

Population, sample and sampling

The study population consisted of public transport drivers (buses and taxis), who worked/resided in Tacna city. First, a pilot was carried out among 30 public transport drivers (not included in the study) in order to calculate the sample size, with statistical power and significance of 80% and 95%, respectively. A minimum sample size of 448 drivers was obtained (adding 10% for possible losses), and they were selected through a systematic random sampling at the main stops in the city.

Drivers who agreed to participate in the study and were 18 years or older were included, while those who were off duty (at the time of the survey) were excluded, as were the collection sheets with inconsistent data (exclusion was less than 5% of the entire sample).

Instrument

The questionnaire was designed by the authors of this study (ad hoc) (S1 File), and a pilot was pre-test to assess the relevance and understanding of the questions in 30 drivers who did not participate in the study. The answers provided by the drivers were obtained to confirm that the questions were understandable.

The questionnaire included the following items: characteristics given at the time of the survey, general and work characteristics of the drivers, previous traffic accident reports, mobile phone use, and seat belt use.

The general characteristics were evaluated, such as sex, age, and degree of education (re-categorized as incomplete/complete). For the labor characteristics, we inquired about the type of transport service (taxi/bus), the characteristics of their work, category of driving license they had, the number of working hours at the time of the survey (re-categorized as less or equal than 5 hours and more than 5 hours, which is the legal maximum for continuous driving hours), the number of daily work hours on average, and years of working experience as drivers. In addition, we asked the drivers if they had been in a traffic accident and whether they had received medical care because of that accident. We also asked whether they had ever used a mobile phone while driving and observed its use during the interview (this is a subject of another study).

For evaluation to seat belt use (dependent variable), we observed if the driver used seat belts (no/yes), if not use, the reasons for not using it were asked, and they were recommended to do so. We checked if the co-driver’s seat was equipped with a seat belt (no/yes). For both safety belts (driver and co-driver), the types of anchorage they had were observed (2 or 3 anchorage points).

Procedures

Data was collected through the field work carried out by the research group and other collaborators, previously trained (denominated interviewers), each of whom objectively observed and obtained answers that were noted in the questionnaire. Each pollster selected the public transport vehicle to be evaluated using a systematic random sampling method, by getting into the first vehicle that transited in service at the authorized stops for picking up passengers (buses) and the second vehicle for the taxi drivers, considering that any vehicle could be selected. The interviewer got into the vehicle and moved close to the front of the vehicles to make a first observation of the driver’s seat belt use. When the vehicle was parked, at a traffic light, or when it stopped, the interviewer explained the objectives of the study to the driver and asked for verbal consent (to avoid the information bias of the dependent variables).

The data was then entered into a data sheet in the Excel 2013 program. The questionnaires were numbered during the data collection (consecutively), this allowed the lead author perform a quality control of the data.

Statistical analysis

After data quality control (using Excel 2013), the data was then entered into the Stata v11.0 statistical program. Descriptive statistics of the drivers’ general characteristics were analyzed, the frequencies and percentages for the categorical variables were evaluated, and after assessing the normality of the continuous variables, the most appropriate measures of central tendency and dispersion were described. Afterwards, the characteristics of the drivers were compared according to their type of public transport, and the p value was calculated using the Chi-square and Student T tests, according to the type of variable.

The dependent variable was the seat belt use that were observed during the interviewer’s first evaluation. Statistical analysis was carried out using generalized linear models (Poisson family models, the log-link function, and robust models, using the type of public transport as a cluster) [18-21], evaluating the raw and adjusted relative risks, the 95% confidence intervals, and the p-value of each crossing. We considered p values <0.05 as statistically significant.

Ethics

The ethics committee of the "Hospital Nacional Docente Madre Niño" in Peru evaluated and approved this project. The authors of the study got a verbal consent from the participants. This verbal consent was obtained before the application of the study. It was witnessed by the pollsters, but it was not documented (to reduce rejection rate). The significance of this study was explained to the drivers, then verbal informed consent was requested (after evaluating the main variables), and the obtained information was anonymized by assigning a unique number to each driver.

Results

Of the 460 public transport drivers assessed, 440 (95.7%) were males, with an average age of 41.9 (standard deviation: ± 9.7 years). About the type of public transport evaluated, 227 of them drove taxis (49.4%) and 233 drove buses (50.6%). Median working hours at the time of evaluation was 5 hours (range: 4–8 hours), and they reported working a median of 12 hours daily (range: 10–14 hours), with 9 years working experience as drivers (range: 5–15 years). Of the total drivers assessed, 77% (356/460) used seat belts, of which 44.4% were taxi drivers and 55.6% were bus drivers (cf .

In the Table 2 we can see the main characteristics of the drivers according to the type of public transport in Tacna-Peru, as well as the main differences between these groups.

Table 2

Characteristics of the drivers according to the type of public transport in Tacna-Peru.

Variable	Type of public transport (drivers)		p value*
	Taxis	Buses
Sex
Female	19 (95.0)	1 (5.0)	< 0.001
Male	208 (47.3)	232 (52.7)
Age (years) ¶	38.8 (0.6)	44.8 (0.6)	< 0.001**
Studies
Incompleted	23 (17.6)	108 (82.4)	< 0.001
Completed	204 (62.1)	125 (37.9)
Driving license (level)
A I	1 (100.0)	0 (0.0)	< 0.001
A II a	110 (100.0)	0 (0.0)
A II b	78 (42.6)	105 (57.4)
A III a	3 (5.6)	51 (94.4)
A III b	2 (14.3)	12 /85.7)
A III c	33 (33.7)	65 (66.3)
Previous traffic fine
No	93 (50.8)	90 (49.2)	0.608
Yes	134 (48.4)	143 (51.6)
Number of previous road accidents¶	0.8 (0.1)	1.6 (0.1)	< 0.001**
Medical attention for road accidents
No	60 (32.4)	125 (67.6)	0.131
Yes	36 (41.9)	50 (58.1)
Reported having used a cell phone while driving (ever)
No	83 (40.7)	121 (59.3)	0.001
Yes	144 (56.3)	112 (43.7)
Type of anchorage of seat belt (drivers)
2 points	12 (17.4)	57 (82.6)	< 0.001
3 points	215 (54.9)	176 (45.1)
Type of anchorage of seat belt (co-drivers)
2 points	12 (10.4)	103 (89.6)	< 0.001
3 points	215 (62.3)	130 (37.7)
Hours of work at the time of evaluation
Less or equal than 5 hours	119 (48.9)	124 (51.1)	0.864
More than 5 hours	108 (49.8)	109 (50.2)
Seat belt use
No	69 (66.4)	35 (33.6)	< 0.001
Yes	158 (44.4)	198 (55.6)

¶ Mean and standard deviation; p values obtained by *Chi square / ** Student´s T.

When the drivers were asked why they did not use their seat belts (104/460 drivers), 46.2% said it was because of perceived discomfort and 30.8% said because of lack of habit (

The bivariate analysis identified some factors associated with seat belt use in public transport drivers. Similarly, it was identified that risk factors decreased with the use of seat belts ().

The multivariate analysis identified male drivers and having seat belts with three anchorage points as factors that increased the use of seat belts. On the contrary, older age, having complete studies, higher classification of driving license, greater number of road traffic accidents as well as having received medical attention because of the accidents, those who reported using the cell phone while driving, vehicles where the co-driver’s belt had 3 anchorage points, and having worked more than 5 hours at the time of the evaluation, were identified as risk factors that decreased the use of the seat belt in public transport drivers (cf.

Discussion

Main findings

We found that 4 out of 5 drivers evaluated used seat belts (77.4%), with differences depending on the type of public transport evaluated. Furthermore, 7 out of 10 taxi drivers used their belts, compared to bus drivers, where 9 out of 10 used the belt. We identified risk factors that modified the frequency of seat belt use in public transport drivers in one Peruvian city.

Prevalence to seat belt use

It was shown that 4 out of 5 public transport drivers were using seat belts during their workday, differing according to the type of public transport evaluated (buses: 56% vs. taxis: 44%; p < 0.001). In our population, the average age and number of road traffic accidents of bus drivers was higher than that of taxi drivers (p < 0.001). We found that 23% of drivers did not use seat belts, and this finding is similar to that of a study of another Peruvian city, where 21% of public transport drivers did not use seat belts [17]. Contrarily, the values are lower than those observed in Bosnia-Herzegovina, where 52% of drivers did not use seat belts in urban areas [7], as well as 30% reported in an African country [22], 62% in two cities in Mexico [16], 63% in two cities in Colombia (with lower use of vans and cars compared to taxis) [15]. Furthermore, in Ethiopia, taxi drivers had twice as much seat belt use as minibus drivers (p = 0.004) [22]. These discrepancies may be due to the different ways and areas in which seat belt use was assessed, as well as cultural, legal and even population differences, and the possibility of overconfidence. Therefore, it is important to make a situational analysis of each reality in order to promote massive strategies to increase the prevalence of seat belt use in the future, which has been shown to decrease mortality from road traffic accidents [23].

When asked why drivers did not wear their seat belts, they said it was because of the perceived discomfort in front of the belt. These findings are consistent with those reported in studies conducted in Iran [24] and Peru [17]. In other settings, drivers who did not use their seatbelts cited disbelief in the safety of the device as a reason for not using it; therefore, they consider it a waste of time [22]. In a study in Colombia, drivers reported simulating the use of their seat belts, using it when they see a traffic policeman or when driving through areas where they could be found, stating that it causes them discomfort [15], and this could be related to the state of the seat belt, and this issue could be reduced by using comfort devices. Similarly, in our study, we observed that drivers pretended to use their belts; therefore, unannounced checks from inside the vehicles (by law enforcers) could increase their use and compliance with the legislation [25].

Risk factors associated to seat belt use

Older people were identified as having less seat belt use, and this contradicts a study by Greene and Smith, who found that a geriatric population over the age of 75 had a higher rate of seat belt use compared to younger people [26]. Similarly, a study in Colombia reported that people over 60, although they drove less, made the most use of safety devices [15]. Thus, developing interventions (such as seat belt reminders in urban settings) and promoting road safety education programs at early ages may yield greater long-term benefits by promoting greater seat belt use [27, 28]. This is contrary to some accredited driver education interventions, who refer do so in order to reduce the number or cost of their traffic fine [25]. It is important to promote a good road safety culture in the general population, which could be reflected over time.

We also found that drivers who reported having completed studies and/or having a higher level/category of driving license used seat belts less, and this is contrary to what was found in Ethiopia, where a higher level of education was positively associated with seat belt use [22]. This association was also reported in the United States [11] and in Bosnia-Herzegovina [7], where higher educational level was a protective factor for increased seat belt use in both urban and rural areas. This may be due to the fact that more educated drivers feel more experienced and less likely to be victims of road traffic accidents, being able to lead overconfidence, thus underestimating the usefulness of seat belts, which may also be due to fatigue over the years. These unexpected results will have to be assessed later in order to target future interventions.

Having more road traffic injuries, with some of them requiring medical attention, was associated with less seat belt use. Seat belt use effectively prevents fatality and serious injury [8, 29]; however, it was noted in our study that despite having more traumatic histories, drivers were not using seat belts. This is similar to what Zabihi et al. reported, where they found a low rate of seat belt use despite the fact that 36% of their population had a history of road traffic accidents [24]. This finding suggested that, despite having a traumatic experience (such as road traffic accidents), some drivers are still unaware of the importance and usefulness of the seat belt.

Those who reported using a cell phone while driving had 20% less seat belt use, similar results were reported in an observational study in Doha, where one in five drivers who used a phone did not use a seat belt, with a higher proportion of the population as seat belt users (p < 0.001) [30]. This was also reported in Florence, where drivers who used phones while driving were 12% less likely to wear seat belts [31]. Similarly, in Saudi Arabia, drivers who had mobile phone-related crashes had less seat belt use [32]. These studies show that drivers who use or report using a mobile phone while driving are less likely to wear a seat belt, although the studies were conducted in different countries, these findings are similar with an observing further that, in some cities where phone use while driving was banned, there was a reduction in driver fatalities [33].

In our study, regarding the type of anchorage, the safety belts evaluated had mainly 3 points, even though some vehicles still had 2 anchorage points (exceptionally allowed for vehicles manufactured before 1980, according to the road safety regulations) [34]. It was observed that drivers who had triple anchorage points on their belts used them more; however, if the co-driver had three anchorage points, they used them less. We found no study to compare this finding with; however, a study in Australia reported that seat belt misuse by both adults and children is very common, regardless of the anchorage points [35]. Likewise, in Ecuador, two investigations conducted to evaluate the resistance of safety belts use reported that the manufacture of these safety devices was not in accordance with the minimum standards of road safety, being a country where two and three anchorage points are mostly used [36, 37]. Although our study did not investigate the characteristics of the belt or the manufacture year of the vehicles, we observed that the belts in some vehicles were modified or adapted, this finding could be decreasing intrinsic properties of the seat belts and its effect in the decrease of mortality, and it could be a reason for future investigations.

In our study, we found that those taxi drivers who had worked for more than 5 hours (on the day of the evaluation) used their seat belt less, although this association has not been reported in previous studies. A study carried out in Argentina reported that 60% of taxi drivers worked more than 10 hours per day, and in that same population, 20% never use seat belts [38]. A longer working time can expose them to a greater work overload, which would be reflected in a lower use of the safety belt and with the potential appearance of health problems like the Burnout Syndrome in drivers of public transportation, evidenced by a study in another Peruvian city, where 20% of drivers had more than 10 years of service [39]. Both findings are risk factors for road traffic accidents [40], which should be evaluated and controlled early.

Limitations and strengths

We had as limitations, the time available to public transport drivers to participate in the evaluation, which inevitably reduced the population size; however, the minimum sample size was reached through a probability sampling, which allows us to see the reality of public transport drivers in the city of Tacna. To reduce the observation bias, the use of seat belts was assessed from inside the vehicle while going up to the transport unit. In the case of drivers who did not use a seatbelt, the evaluators asked why they did not use this device and recommended using it at the beginning of the interview.

Conclusions

Four out of five public transport drivers in Tacna used seat belts, with differences depending on the type of public transport. Similarly, factors that modified the frequency of seat belt use in public transport drivers in one Peruvian city were identified. These results show the reality of safety belts use in public transport drivers, allowing the authorities to apply control measures to increase the use. These measures can reduce the morbidity and mortality burden of road traffic accidents, which represent a major problem in our country.

Questionnaire.

(PDF)

Click here for additional data file.

(PDF)

Click here for additional data file.

26 Oct 2020

PONE-D-20-30480

Use of seat belts among public transport drivers in Tacna, Peru: Prevalence and risk factors

PLOS ONE

Dear Dr. Miñan-Tapia,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Dec 10 2020 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Feng Chen

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. In the ethics statement in the Methods section and online submission information, please specify the type of informed consent that was obtained from the participants (for instance, written or verbal, and if verbal, how it was documented and witnessed).

3. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information, or include a citation if it has been published previously.

4. In the Methods, please discuss whether and how the questionnaire was validated and/or pre-tested. If these did not occur, please provide the rationale for not doing so.

5.  We suggest you thoroughly copyedit your manuscript for language usage, spelling, and grammar. If you do not know anyone who can help you do this, you may wish to consider employing a professional scientific editing service.

Whilst you may use any professional scientific editing service of your choice, PLOS has partnered with both American Journal Experts (AJE) and Editage to provide discounted services to PLOS authors. Both organizations have experience helping authors meet PLOS guidelines and can provide language editing, translation, manuscript formatting, and figure formatting to ensure your manuscript meets our submission guidelines. To take advantage of our partnership with AJE, visit the AJE website (http://learn.aje.com/plos/) for a 15% discount off AJE services. To take advantage of our partnership with Editage, visit the Editage website (www.editage.com) and enter referral code PLOSEDIT for a 15% discount off Editage services.  If the PLOS editorial team finds any language issues in text that either AJE or Editage has edited, the service provider will re-edit the text for free.

Upon resubmission, please provide the following:

The name of the colleague or the details of the professional service that edited your manuscript

A copy of your manuscript showing your changes by either highlighting them or using track changes (uploaded as a *supporting information* file)

A clean copy of the edited manuscript (uploaded as the new *manuscript* file)

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Partly

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: N/A

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: This paper investigates the prevalence and influencing factors of seat-belts usage among public transport drivers in Tacna, Peru. The research topic is interesting and worth of investigation. However, the introduction on the proposed generalized linear model is somewhat vague. The authors are suggested to explicitly specify the formulations of the proposed methods and illustrate why they are suitable to model the use of seat belts. Moreover, some references on univariate/bivariate/multivariate generalized linear models should be added, such as:

A multivariate random parameters Tobit model for analyzing highway crash rate by injury severity. Accident Analysis and Prevention, 2017, 99: 184-191.

Jointly modeling area-level crash rates by severity: A Bayesian multivariate random-parameters spatio-temporal Tobit regression. Transportmetrica A: Transport Science, 2019, 15(2): 1867-1884.

Spatial joint analysis for zonal daytime and nighttime crash frequencies using a Bayesian bivariate conditional autoregressive model. Journal of Transportation Safety and Security, 2020, 12(4): 566-585.

Besides, the English writing should be improved.

Reviewer #2: The topic of this paper is interesting. The methods sound. The results are meaningful and useful. There are several suggestions to improve this paper.

1. More discussion about the methods used in this field is needed. And more references about different methods could be added. For example, the following ones about logit models are needed.

[1] Investigating the Impacts of Real-Time Weather Conditions on Freeway Crash Severity: A Bayesian Spatial Analysis, International Journal of Environmental Research and Public Health, 2020, 17(8): 2768.

[2] Investigation on the Injury Severity of Drivers in Rear-End Collisions Between Cars Using a Random Parameters Bivariate Ordered Probit Model, International Journal of Environmental Research and Public Health, 2019, 16(14) , 2632.

2. A table of the basic statistical information of the variables are needed.

3. The English writting could be improved.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

2 Apr 2021

1. Comments of the reviewers: In the ethics statement in the Methods section and online submission information, please specify the type of informed consent that was obtained from the participants (for instance, written or verbal, and if verbal, how it was documented and witnessed).

Comments of the authors: The authors of the study got a verbal consent from the participants. This verbal consent was obtained before the application of the study. It was witnessed by the pollsters, but it was not documented (to reduce rejection rate). Outcome evaluation (use the cellphone and seat belt use) was performed since the pollsters got into the vehicle (to avoid information bias), being one of the first reports of the use of seat belt in public transport drivers assessed from inside the vehicle

2. Comments of the reviewers: Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information, or include a citation if it has been published previously.

Comments of the authors: We have provided more information about the scale and we will be sending the scale in the support information, in its original version (Spanish) and in the English language.

3. Comments of the reviewers: In the Methods, please discuss whether and how the questionnaire was validated and/or pre-tested. If these did not occur, please provide the rationale for not doing so.

Comments of the authors: We have clarified this item in the methods section.

4. Comments of the reviewers: We suggest you thoroughly copyedit your manuscript for language usage, spelling, and grammar. If you do not know anyone who can help you do this, you may wish to consider employing a professional scientific editing service.

Comments of the authors: We have improved it.

5. Comments of the reviewers: the introduction on the proposed generalized linear model is somewhat vague.The authors are suggested to explicitly specify the formulations of the proposed methods and illustrate why they are suitable to model the use of seat belts.

Comments of the authors: The generalized linear regression model was performed, using the Poisson family with robust variance to find the risk factors associated with greater or lesser use of a seat belt (outcome / main / dependent variable). This model was preferred due to the study design (cross-sectional), due to the dichotomous outcome, and to unify the statistical models, relating the random variable (use of a seat belt) with the systematic component (other independent variables evaluated), thus adjusting the model by potential confounding variables. This generalized linear model is proposed by the Peruvian transport authorities to make estimates of accidents and other issues related to road safety in transport, [1] as well as studies that evaluate behaviors dependent on drivers. [2]

Our study does not directly assess the characteristics of traffic accidents, nor the trend of these, however, the use of seat belts is part of the road safety devices that can have a decrease in the rates of morbidity and mortality in the drivers.

6. Comments of the reviewers: Some references on univariate/bivariate/multivariate generalized linear models should be added.

Comments of the authors: We have added the suggested references.

7. Comments of the reviewers: More discussion about the methods used in this field is needed. And more references about different methods could be added.

Comments of the authors: We have added the suggested references.

8. Comments of the reviewers: A table of the basic statistical information of the variables are needed.

Comments of the authors: We have added the basic statistical information of the variables evaluated in public transport drivers in table 01

9. Comments of the reviewers: The English writting could be improved.

Comments of the authors: We have improved it.

References

1. Ministerio de Transportes y Comunicaciones. Manual de Seguridad Vial. Lima - Perú; 2017. Avaible in: https://portal.mtc.gob.pe/transportes/caminos/normas_carreteras/documentos/manuales/Manual_de_Seguridad_Vial_2017.pdf?fbclid=IwAR37pfT4iC6gUom_o-0ceucgVt2qwlrX5ICH7YgvwSvEIEjAMLfjimyo1P8 (accesed on 30/03/21)

2. Gershon P, Ehsani J, Zhu C, O'Brien F, Klauer S, Dingus T, et al. Vehicle ownership and other predictors of teenagers risky driving behavior: Evidence from a naturalistic driving study. Accid Anal Prev. 2018;118: 96-101.

Submitted filename: 210329_Response to the Reviewers.docx

Click here for additional data file.

4 May 2021

Use of seat belts among public transport drivers in Tacna, Peru: Prevalence and risk factors

PONE-D-20-30480R1

Dear Dr. Miñan-Tapia,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Feng Chen

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: (No Response)

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: (No Response)

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: (No Response)

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: (No Response)

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: (No Response)

Reviewer #2: (No Response)

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

6 May 2021

PONE-D-20-30480R1

Use of seat belts among public transport drivers in Tacna, Peru: Prevalence and risk factors

Dear Dr. Miñan-Tapia:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Feng Chen

Academic Editor

PLOS ONE

Table 1

General characteristics of the drivers evaluated.

Variable	N	%
Sex
Female	20	4.4
Male	440	95.6
Age (years)¶	41.9	± 9.7
Studies
Incompleted	131	28.5
Completed	329	71.5
Driving license (level)
A I	1	0.22
A II a	110	23.9
A II b	183	39.8
A III a	54	11.7
A III b	14	3.1
A III c	98	21.3
Previous traffic fine
No	189	41.1
Yes	271	58.9
Number of previous road accidentsβ	1	0–2
Medical attention for road accidents
No	185	68.3
Yes	86	31.7
Type of anchorage of seat belt (drivers)
2 points	69	15
3 points	391	85
Type of anchorage of seat belt (co-drivers)
2 points	115	25
3 points	345	75
Hours of work at the time of evaluation
Less or equal than 5 hours	243	52.8
More than 5 hours	217	47.2
Seat belt use
No	104	22.6
Yes	356	77.4
Type of public transport
Taxis	227	49.4
Buses	233	50.6

¶ Mean and standard deviation.

β Median and interquartile range.

Table 3

Bivariate analysis of the risk factors associated with the use of seat belts among public transport drivers in Tacna-Peru.

Variable	Seat belt use		Bivariate analysis
	Yes	No	cRR	CI95%	p value
Sex
Female	7 (35.0)	13 (65.0)	Comparison category
Male	349 (79.3)	91 (20.1)	2.27	1.59–3.23	< 0.001
Age (years)	42.3	40.4	1.00	1.00–1.01	< 0.001
Studies
Incompleted	109 (83.2)	22 (16.8)	Comparison category
Completed	247 (75.1)	82 (24.9)	0.90	0.82–0.99	0.027
Driving license (level)
A I	1 (100.0)	0 (0.0)	Comparison category
A II a	59 (53.6)	51 (46.4)	The result does not converge
A II b	163 (89.1)	20 (10.9)	0.89	0.79–0.99	0.035
A III a	47 (87.0)	7 (13.0)	0.87	0.83–0.92	< 0.001
A III b	11 (78.6)	3 (21.4)	0.79	0.64–0.96	0.020
A III c	75 (76.5)	23 (23.5)	0.77	0.59–0.98	0.035
Previous traffic fine
No	136 (74.3)	47 (25.7)	Comparison category
Yes	220 (79.4)	57 (20.6)	1.07	1.04–1.10	< 0.001
Number of previous road accidents	1.2 (0.08)	1.0 (0.13)	1.02	0.94–1.11	0.610
Medical attention for road accidents
No	163 (88.1)	22 (11.9)	Comparison category
Yes	60 (69.8)	26 (30.2)	0.79	0.61–1.03	0.083
Reported having used a cell phone while driving (ever)
No	180 (88.2)	24 (11.8)	Comparison category
Yes	176 (68.8)	80 (31.2)	0.78	0.63–0.97	0.025
Type of anchorage of seat belt (drivers)
2 points	47 (68.1)	22 (31.9)	Comparison category
3 points	309 (79.1)	82 (20.9)	1.16	1.01–1.34	0.040
Type of anchorage of seat belt (co-drivers)
2 points	96 (83.5)	19 (16.5)	Comparison category
3 points	260 (75.4)	85 (24.6)	0.90	0.86–0.94	< 0.001
Hours of work at the time of evaluation
Less or equal than 5 hours	188 (77.4)	55 (22.6)	Comparison category
More than 5 hours	168 (77.4)	49 (22.6)	1.00	0.87–1.16	0.993
Drivers
Taxis	158 (69.6)	69 (30.4)	Comparison category
Buses	198 (84.9)	35 (15.1)	1.22	1.22–1.22	< 0.001

Crude relative risks, 95% confidence intervals and p-values were obtained with the Poisson family models, the log-link function, and robust models, using the type of public transport (bus or taxi) as a cluster; all with the generalized linear models.

Table 4

Multivariate analysis of risk factors associated with seat belt use among public transport drivers in Tacna-Peru.

Variables	Relative Risk	Confidence Interval 95%	p value
Male sex	2.19	2.09–2.30	<0.001
Age (years)	0.997	0.997–0.997	<0.001
Completed studies	0.99	0.98–0.99	<0.001
Driving license (level)
A I	Comparison category
A II a	0.72	0.71–0.72	<0.001
A II b	0.81	0.78–0.84	<0.001
A III a	0.78	0.75–0.81	<0.001
A III b	0.95	0.76–1.17	0.612
A III c	0.77	0.60–0.99	0.043
Have a previous traffic fine	0.99	0.89–1.11	0.882
Number of previous road accidents	0.97	0.95–0.99	0.011
Medical attention for road accidents	0.86	0.81–0.93	<0.001
Reported having used a cell phone while driving	0.80	0.68–0.93	0.005
Driver’s belt with 2 anchorage points	1.50	1.31–1.73	<0.001
Co-driver’s belt with 3 anchorage points	0.77	0.77–0.77	<0.001
More than 5 hours of work at the time of evaluation	0.97	0.96–0.99	0.002

Relative risks, 95% confidence intervals and p-values were obtained with the Poisson family models, the log-link function, and robust models, using the type of public transport (bus or taxi) as a cluster; all with the generalized linear models.