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Objectives: Wearing a helmet is the single most effective measure for preventing head injuries in motorcycle users. The authors undertook this study to estimate compliance and determine reasons for noncompliance with helmet use among motorcyclists in their community.
Methods: This was a cross-sectional survey of motorcyclists in three large randomly selected public-access parking spaces across Karachi, Pakistan’s largest city. Questions covered personal demographics, frequency of helmet use, reasons for use or nonuse, and knowledge of local helmet laws. Analysis was based on frequencies and group comparisons using chi-square test or independent sample t-test.
Results: Of the 300 (100% male) subjects, 169 (56%) reported using helmets regularly. Users listed injury prevention (78%) as the major reason for compliance, while nonusers listed physical discomfort (44%) and limited vision (25%) as the leading reasons for noncompliance. In univariate analysis, helmet users were significantly better educated than nonusers and were more likely to believe that helmets are protective (p = 0.002) and that passengers should also wear helmets (p < 0.001). The significance of these variables persisted in multivariate analysis. Several other variables (such as mean age, marital status, and knowledge of helmet laws) did not differ between users and nonusers.
Conclusions: Helmets are underused by motorcyclists in the authors’ community. This study underscores the need for improved helmet design, public understanding, intense public education, and rigorous law enforcement in raising compliance with helmet use and minimizing the risk of preventable trauma.
Road traffic accidents account for more than 1 million deaths annually worldwide, the great majority of which (up to 85%) occur in middle- and low-income countries.1 For every road traffic fatality, several more victims are left permanently disabled. In the 1990s, road traffic injuries ranked ninth in terms of global disease burden and are estimated to become the third leading cause of global disease burden by 2020.2 In developed countries, the bulk of road traffic fatalities involve four-wheeled vehicles, but in developing countries motorized two-wheeled vehicles (motorcycles) account for a substantial proportion.1
An increasingly popular means of transport, motorcycles represent the fastest growing segment of vehicular transport. Motorized two-wheelers comprise 63 and 69%, respectively, of all motor vehicles in China and India, the world’s two most populous nations. In keeping with the growing numbers of motorcycles on the road, there are increased rates of fatal road traffic accidents. Although motorcycles account for only 5% to 10% of road traffic deaths in the United States and Australia, they are involved in 40% to 70% of road fatalities in countries such as Indonesia, Malaysia, and Thailand.3
Trauma to the head and neck is the primary cause of death and severe disability in motorcycle-related accidents. Wearing a helmet can provide life-saving protection in motorcycle accidents,4 but compliance with helmet use is far from universal.
We undertook this study to identify factors associated with helmet use in Pakistan, a middle-income country where motorcycles are a common mode of transport. Our aims were to estimate the frequency of helmet use and to identify factors associated with helmet wearing, in the hopes of more effective policy and legislation directed at road traffic safety.
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A total of 300 motorcyclists completed the interview, 100 from each parking lot. All (100%) respondents were male, in keeping with the prevailing trend in South Asia, where women seldom drive motorcycles. A majority (56.3%; n = 169) reported using a helmet always or almost always and were classified as users; the remaining 43.7% (n = 131) reported wearing a helmet never or almost never and were classified as nonusers.
Table 1 compares the two groups in terms of several variables. In univariate analysis, users were found to be better educated, being 2.3 times more likely than nonusers to have earned a graduate degree (p < 0.001); in addition, users were significantly more likely to believe that helmets are protective (p = 0.002) and that passengers should also wear helmets (p < 0.001). The significance of these variables persisted in multiple logistic regression. Univariate analysis also revealed that users were more likely to have a higher personal income, although the statistical significance was borderline (p = 0.057; OR 1.6; 95% CI = 1.0 to 2.6), and the effect disappeared in multivariate analysis.
Table 1. Comparison of Helmet Users and Nonusers
|Variable||Helmet Users (n = 169)||Helmet Nonusers (n = 131)||p-Value|| OR (95% CI)||Adjusted OR (95% CI)*|
|Believe that helmets are protective||161 (95.3%)||109 (83.2%)||0.002||4.1 (1.7, 9.5)||2.5 (1.0, 6.3)|
|Believe that passengers should also wear helmets†||133 (78.7%)||72 (55.0%)||<0.001||3.0 (1.8, 5.0)||2.3 (1.4, 4.1)|
|Mean age, yr (± SD)||32.5 ± 9.7||30.9 ± 10.3||NS||1.6 (0.0, 3.9)‡||—|
|Married||95 (56.2%)||68 (51.9%)||NS||1.2 (0.8, 1.9)||—|
|Have children||86 (50.9%)||60 (45.8%)||NS||1.2 (0.8, 1.9)||—|
|Earned graduate degree or higher||103 (60.9%)||53 (40.5%)||<0.001||2.3 (1.4, 3.7)||1.9 (1.2, 3.2)|
|Monthly income US$170 or less||98 (58.0%)||90 (68.7%)||0.057||1.6 (1.0, 2.6)||—|
|Seen advertisements for helmet use||114 (67.5%)||81 (61.8%)||NS||1.3 (0.8, 2.1)||—|
|Aware of relevant traffic laws||133 (78.7%)||99 (75.6%)||NS||1.2 (0.7, 2.1)||—|
|History of being stopped by police||62 (36.9%)||46 (35.1%)||NS||1.1 (0.7, 1.7)||—|
Awareness of helmet safety was incomplete. Although most respondents (77.3%; n = 232) acknowledged that helmet wearing was required by law, 65% (n = 195) had seen public awareness messages advocating for helmets, and 36% had been stopped by the police for not wearing a helmet. These factors were not preferentially associated with helmet use. Several other variables, including mean age, marital status, and having children, also did not differ between users and nonusers.
Table 2 summarizes the reasons cited by helmet users and nonusers for their preference. Respondents were asked to choose as many reasons as applied from a menu of possibilities; they were also free to cite any reason(s) not covered by the given options. Protection from injury was cited as the leading reason for wearing a helmet (78%), followed by protection from dust (50%), history of an unprotected motorcycle accident (35%), and knowledge of someone else getting hurt in an unprotected motorcycle accident (33%). Nonusers cited the helmet’s bulk and inconvenience (44%), physical discomfort from heat (34%), and limited vision (25%) as the main reasons for not wearing helmets.
Table 2. Reasons for Using or Not Using Helmets
|Users (n = 169)|
| Protection from injury||78|
| Protection from dust||50|
| History of previous fall||35|
| Knowledge of someone else’s injury||33|
| Fear of police||12|
| Keeping hair in shape||10|
|Nonusers (n = 131)|
| Physical bulk and discomfort||44|
| Limited visual field||25|
| Is not protective||5|
| Too expensive||4|
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Pakistan is a middle-income country in which the problem of road traffic injuries has been described as an “emerging epidemic.” During a 40-year period between 1956 and 1996, there was a 16-fold increase in the number of fatal motor vehicle accidents and a 14-fold increase in the total number of motor vehicle crashes.5 These figures are based on self-reported data and may be gross underestimates. Motorcycles comprise nearly half (48%) of Pakistan’s registered transport vehicles.6
Studies of head injury patients presenting to Pakistan’s large tertiary-care hospitals reveal road trauma as a major cause. A comprehensive 4-year prospective multicenter survey from 1995 through 1999 found road traffic accidents to be the commonest cause of head injury, accounting for 137,280 (52.8%) of 260,000 cases; males were overrepresented 3:1 and overall mortality was 18%, while 67% of patients eventually had a good outcome as measured by the Glasgow Outcome Scale.7 In this study, motorcycles were implicated in at least 3% of the road injuries, of which the majority of drivers (90%) did not wear helmets.7 The small proportion of motorcycle injuries may be explained by sampling from rural areas, where motorcycle use was relatively less common in the 1990s. On a smaller scale, an emergency department audit of head injuries from Karachi found road trauma accounting for 79 (76.7%) of 103 cases; males were overrepresented 4:1, and overall mortality was 12.6%, while the majority (74.7%) had a good outcome.8 Motorcycles were implicated in at least 19% of the injuries in this study. A study of zygomatic bone fractures in Lahore, Pakistan’s second largest city, found motorcycle accidents to be the commonest cause of this type of injury.9
Prevalence of helmet use among motorcyclists varies widely across countries and regions. A study from Pamplona, Spain, observed 19.7% motorcycle drivers wearing helmets; this increased to 94.8% after enforcement of a local helmet law.10 In another study, 89% motorcyclists in urban Indonesia were found to be wearing helmets,11 while a study from Vietnam noted 30% average helmet use by motorcyclists.12 Our finding of 56% compliance with helmet use compares favorably with regional figures. However, because it is based on a self-reported survey rather than direct observation of motorcycle riders, it may be an overestimate.
We found that helmet use is associated with better education and marginally associated with better personal income; these findings are in keeping with the worldwide observation that low socioeconomic status increases risk for injury13 and offers hope that improving public education will lead to greater compliance with helmets and other safety measures. Although we also found that a belief in the protective properties of helmets was strongly associated with helmet use, other variables, such as having a family and awareness of helmet laws, were not overrepresented among helmet users. Of the 131 nonusers in our study, 99 (76%) knew that helmet wearing was required by law, 81 (62%) had seen public advertising advocating helmet use, and 46 (35%) had previously been stopped by the police for helmet law infringement. These data suggest that the public policy approach towards improving helmet use needs to be reformulated. In keeping with the literature, our study observed that the main reason (cited by 44% of nonusers) for not wearing helmets was physical inconvenience and discomfort; in a study from Athens, Greece, 46% of nonusers listed physical discomfort associated with the helmet as the primary reason for noncompliance.14
The findings of our study have implications for policy makers and law enforcement. Future studies are needed to verify our observations in a larger sample, as well as through directly observed motorcyclist behavior. These can be expected to serve as a prelude to formulating and testing interventions aimed at prevention of head injury in motorcyclists and their passengers.