, Seat belt use is a fundamental road safety requirement and has been shown to markedly reduce the risk of serious and fatal injuries resulting from motor vehicle crashes. Despite this benefit, seat belt nonuse remains prevalent among drivers and passengers [1]. To address this issue, in addition to direct interventions [2], identifying modifiable factors associated with seat belt use is important for developing targeted strategies. Previous studies have identified various correlates of seat belt use [3], including human factors that critically influence compliance.
Health literacy (HL), an individual’s ability to access, comprehend, evaluate, and apply health information to health and safety decisions [4], is associated with various health behaviors [5]. To the best of our knowledge, evidence remains limited, with very few studies examining the relationship between HL and seat belt use [6], reporting no significant association. However, the study focused on older adults in the United States, used a small convenience sample, and employed an HL measure centered on medical comprehension. In contrast, our study used nationally representative data and a comprehensive HL instrument encompassing broader HL dimensions. These methodological and contextual differences highlight the need to re-examine the association between HL and seat belt use in diverse populations. Accordingly, using data from the Korean National Health and Nutrition Examination Survey (KNHANES), this study aimed to examine the association between HL and seat belt use among Korean adults.
This cross-sectional analysis used data from the 2023 KNHANES, which employed a stratified multistage probability sampling design [7]. Data from 5,906 adults aged 19 years or older with complete HL information were included in the analysis. The ethics approval for the survey protocol was granted by the Korea Disease Control and Prevention Agency, and all participants provided informed consent before data collection. All participants provided written informed consent, and researchers followed the Declaration of Helsinki guidelines. The Institutional Review Board (IRB) of the Korea Centers for Disease Control and Prevention approved KNHANES. The study protocol was approved by the IRB of the Gil Medical Center (IRB approval No. GBIRB2025-093).
HL was measured using the Health Literacy Index for the Community (HLIC), which comprises 10 items spanning three domains: disease prevention, health promotion, and technology/resources. The total HLIC score ranges from 10 to 40, and participants scoring <28 were classified as having inadequate HL [8]. Seat belt usage was evaluated for the driver, front passenger, and rear passengers; only participants who responded “always wear” were assigned to the seat belt use group.
The following covariates were entered into the analysis: age, sex, economic status, educational level, current employment, marital status, current smoking status, frequent alcohol consumption, engagement in aerobic physical activity, obesity, hypertension or type 2 diabetes, stress, depressive mood lasting for ≥2 weeks within the past year, anxiety (generalized anxiety disorder scale score of ≥10), and self-rated health status (good vs. not good). Participant characteristics were summarized using weighted means and standard errors or weighted proportions from the complex survey analysis, as appropriate. Multivariable survey logistic regression models were used to determine the independent factors associated with seat belt nonuse. All statistical tests were two-sided, and P<0.05 were considered statistically significant. The analysis was conducted using STATA MP 17.0, with the survey command (svy: logit) (StataCorp LLC, College Station, TX, USA).
The prevalence of inadequate HL in the Korean population was 23.3% (weighted). Members of the inadequate-HL group were older and had a poorer socioeconomic status, including lower income, lower education levels, higher unemployment, and unmarried status (P<0.001 for all). They also participated in aerobic exercise less regularly and had higher current smoking rates, more comorbidities, higher anxiety levels, and poorer self-rated health. This group also used seat belts less often in the driver and front passenger seats (Table 1). The factors associated with seat belt nonuse from the multivariable survey logistic regression are shown in Table 2. Specifically, inadequate HL was associated with increased odds of not wearing a seat belt in the driver’s seat (odds ratio, 1.63; 95% confidence interval, 1.25-2.13) and front passenger seats (odds ratio, 1.37; 95% confidence interval, 1.14-1.65).
This study shows that inadequate HL is independently associated with higher odds of seat belt nonuse in driver and front passenger seats, highlighting the important association between HL and road safety behavior among Korean adults. Although seat belt use in Korea has gradually increased following legislative changes and public health campaigns, a meaningful minority does not comply with seat belt laws. Our findings suggest that higher HL levels are associated with greater seat belt compliance and may ultimately contribute to fewer traffic-related injuries.
Notably, inadequate HL was not associated with seat belt use in the rear seats. This null finding may reflect a ceiling effect, because the overall prevalence of rear seat belt nonuse was high (approximately 76% in both HL groups), leaving little variability in the detection of an association. In addition, rear seat belt use may be more strongly influenced by situational or contextual norms, such as using taxis or public transportation, rather than by individual-level HL. These factors could attenuate the relationship between HL and rear seat belt use, warranting further investigation in future studies that account for travel context and transportation mode.
Several studies have explored the relationship between HL and traffic safety behaviors in the general population. A Polish study identified noncompliance and inattention to traffic regulations as major contributors to road traffic injuries, thus emphasizing the need for behavioral changes and improving HL at the societal level [9]. Interestingly, an Iranian study concluded that HL significantly influenced pedestrian safety behavior [10]. Together with our results, these studies underscore that HL is positively associated with informed and safe traffic behaviors. Therefore, tailored interventions aimed at improving HL are essential to empower individuals to make informed choices regarding personal safety.
This study had some limitations. First, its cross-sectional design prevented us from establishing causal relationships between the observed variables. Second, the reliance on self-reported data may have introduced a recall bias and potentially reduced the accuracy of the measured HL status, health-related factors, and socioeconomic characteristics. Third, our analysis did not account for other potential confounders, such as previous traffic accident experience, peer seat belt use behavior, or regional differences in seat belt law enforcement. Despite these limitations, our findings highlight the potential association between low HL and seat belt nonuse, suggesting that HL improvement could be an important consideration for promoting seat belt use. Future interventional investigations are required to confirm these findings.
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