Barriers to, and factors associated, with observed motorcycle helmet use in Vietnam

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Abstract

This study investigated barriers to, and factors associated with, observed motorcycle helmet use among motorcyclists in Hai Duong Province, Vietnam. The findings highlighted an array of factors associated with observed helmet use namely, support for universal helmet legislation and a positive attitude towards what might be perceived as negative attributes of helmet use such as inconvenience and discomfort in hot weather. As well, older age (greater than 25 years in age), riding on a compulsory road, being a driver, trips of greater than 10 km, higher levels of education (having a university degree and higher) were found to be key determinants of helmet use. Despite over 95% of motorcyclists disagreeing with the statement that wearing a helmet does not reduce the severity of head injury in a crash, most motorcyclists believed that helmets did not need to be worn for a short trip. Overall, only 23% of motorcyclists were observed wearing a helmet. The authors conclude that efforts to increase helmet use need to focus on the necessity for universal helmet legislation in association with identifying solutions to reduce the negative attitudes towards helmet use.

Introduction

Road traffic collisions on Vietnam's roads claim five times more lives now than they did 10 years ago. In 2002 a total of 20,774 crashes were reported, leading to 12,864 deaths and 29,827 hospitalizations, while these figures in 1994 were 4907 and 14,174, respectively (MOH, 2004). Motorcycles are the most popular means of transport in Vietnam with 95% of registered motor vehicles being motorcycles. It is not surprising therefore, that motorcycles account for up to 70% of road traffic crashes and 88% of road deaths due to head injuries.

Substantial evidence is available that motorcycle helmets are highly effective in preventing head injury in the event of a collision with a recent systematic review indicating that helmets reduce the risk of head injury by up to 72% (Lui et al., 2003). Motorcycle helmet legislation is widely enforced in many high-income countries where it is seen as an effective countermeasure; such legislation is less common in low and middle-income countries despite the vast burden of motorcycle related head injuries.

Helmet legislation was first introduced in Vietnam in August 2000, with amendments in 2001 and 2003 which required compulsory use of motorcycle helmets on assigned routes and national roads. There are fines applicable for not wearing a helmet while travelling on compulsory roads; a fine of VND 20,000–40,000 (US$ 1.3–2.25) which accounts for approximately 2.6–4.5% of the average monthly income per person. There is no penalty for the use of non-standard helmets or the incorrect use of a helmet. Overall, the use of helmets is low in Vietnam with a recent population-based estimate indicating the prevalence is as low as 30% (Hung et al., 2006) with a large difference in the helmet use between compulsory and non-compulsory roads (40–60% vs. 10%, respectively).

Helmet use is known to be associated with age, the gender and position of the motorcyclists on the motorbike, the type of road travelled on, the nature of the trip, time, weather, a history of motorcycle injury (Mangus et al., 2004), and level of enforcement (Kulanthayan et al., 2000). Helmet users are more likely to be drivers as shown by studies in Indonesia (Corad et al., 1996), China (Zhang, 2004), Spain (Guillen Grima et al., 1995) and Vietnam (Hung et al., 2006), of an older age (Hung et al., 2006, Kulanthayan et al., 2000, Skalkidou et al., 1999), more likely to be riding a long distance (Allegrante et al., 1980, Kulanthayan et al., 2000), travelling on highways or freeways, and/or in an urban area (Kulanthayan et al., 2000, Skalkidou et al., 1999, Hung et al., 2006). Other factors associated with helmet use include whether the trip is during the week (Monday–Friday) and during the day (Corad et al., 1996, Skalkidou et al., 1999); in winter (Kraus et al., 1995, Lund et al., 1991); whether the driver holds a drivers license (Reeder et al., 1997); whether there is likely to be police presence (Kulanthayan et al., 2000, Corad et al., 1996). With respect to gender, studies in Thailand (Ichikawa et al., 2003) as well as in the U.S. (Youngblood, 1980) have found that men are less likely to wear a helmet as compared to women while in contrast, research in Vietnam shows the inverse (Hung et al., 2006). Legislation also has an influence on helmet use, yet its effect is higher in higher income countries where compliance reached nearly 100% (Ulmer and Preusser, 2002, Houston, 2007, Servadei et al., 2003, Guillen Grima et al., 1995); as compared to low and middle-income countries (Ichikawa et al., 2003, Hung et al., 2006). Research in Thailand (Swaddiwudhipong et al., 1998) showed motorcyclist education increased helmet use. The lack of comfort, a negative social perception and the inconvenience of helmets particularly in relation to storage of helmets when not riding, have further been posited as reasons for lower helmet use (Guillen Grima et al., 1995, WHO, 2006). In some high-income countries, helmet use has been described as a violation of personal freedom as well as suggesting that helmets impair vision and hearing (NHTSA, 1997). Although such propositions are moot, research has found that motorcycle helmets can reduce a motorcyclist's lateral vision however, motorcyclists adjust for this by increasing their head rotation (NHTSA, 1997).

Research in high-income countries has attempted to explain the use of helmets by understanding a motorcyclist's knowledge and attitude towards helmet use. Lindauer and Ritzel (1978) found that a motorcyclist's attitude was a predictor of helmet use particularly in jurisdictions in which there was no mandatory law for helmet use. Similarly, Allegrante et al. (1980) found that those intending to use a helmet differed from non-intenders on factors such as their belief related to safety and comfort/convenience. Youngblood (1980) found that a motorcyclist's attitude is more important than their knowledge of the benefits of helmet use in their decision to wear a helmet. Bianco et al. (2005) studied a sample of 387 adolescents in Italy and found that the reasons for not wearing a helmet were predominantly discomfort and lack of ownership of a helmet.

There are few studies investigating the association between a motorcyclists’ attitude and observed helmet use in low and middle-income countries. This is certainly the situation in Vietnam—a country where the mode of transport is predominantly by motorcycle. Hence, the objective of this study is to investigate factors (including barriers to use) associated with motorcycle helmet use in Vietnam.

Section snippets

Methods

A cross-sectional survey of motorcyclists (including drivers and passengers) was undertaken in Hai Duong Province. The province is situated in the Red River Delta region of northern Vietnam which is approximately 60 km from the capital of Hanoi. The province has a population of 1.7 million (HDPC, 2006) and in 2006 had 318,000 registered motorcycles, an increase from 79,000 in 2000. Motorcycles account for 94.5% of the total registered vehicles in the province. The road network comprises five

Sample statistics and prevalence of helmet use

A total of 1184 motorcyclists were approached and 822 (69.4%) agreed to complete a 20-min interview of whom 808 (68.2%) were eligible for analysis (14 cases were excluded due to missing data) including 716 drivers and 92 passengers. The mean age was 35.7 years and 654 (80.9%) were male and 154 (19.1%) female. License ownership was high among drivers with 93.16% (n = 667) of drivers and 52.2% (n = 48) of passengers reporting they had a driver's license.

Of the sample observed, 187 (23.1%) were

Discussion

This is the first study to identify key barriers and factors associated with observed helmet use in Vietnam and it is important to interpret the findings from the background of a very low level of helmet use. The prevalence of helmet use in this study namely, 23% of motorcyclists were observed wearing a helmet, is in accordance with an earlier study also conducted by the authors in Vietnam (Hung et al., 2006). The findings from this study provide an explanation, in part, as to why few

Conclusion

This study confirms that older aged motorcyclists, motorcycle drivers (rather than passengers), the length of the trip (greater than 10 km), travelling on a mandated road and having a university-level education are associated with the helmet use. Efforts to increase helmet use would need to focus on reducing community perceptions about the negative effects of helmet use. The reality however is, that in the absence of rigorously enforced universal helmet legislation, it is unlikely that the

Acknowledgements

We acknowledge with thanks the Hai Duong's Provincial Health Service and Hai Duong's Department of Transportation, Hai Duong's Provincial Department of Fire Control and the Division of Urban Administration of Hai Duong city People Committee for providing road data, maps, legislative documents and list of petrol stations. Dr. Dang Viet Hung is funded by an AusAID (Australian Agency for International Development) Doctoral Scholarship and financial assistance for this project was provided by The

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