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Abstract
Introduction Road traffic injuries (RTIs), particularly motorbike injuries, are one of the leading causes of death worldwide and have been a serious concern in low- and middle-income countries like Bangladesh. Therefore, this study aimed to assess the level of knowledge and practices on road safety measures among motorbikers in Dhaka, Bangladesh.
Methods This cross-sectional study was conducted from January 2022 to December 2022 among 350 motorbikers of Dhaka city via a series of face-to-face interviews. Motorbikers who regularly ride a motorcycle were interviewed about their road safety knowledge and practices through a two-stage cluster sampling technique. Frequency distribution, independent sample t-test and one-way analysis of variance (ANOVA) were performed in data analysis.
Results Out of the 350 motorbikers, only 54.6% had good knowledge and 16.9% had poor knowledge on the signs and safety regulations of roads. Moreover, only 50.6% of respondents followed good practices while 23.4% followed poor practices of road safety measures. One-way ANOVA analysis demonstrates that the average knowledge score was significantly (p<0.05) higher among higher-educated, unmarried and non-smokers. Additionally, higher education level, non-smoking status and being Muslim were significantly (p<0.05) associated with good road safety practices.
Conclusions The overall good knowledge level and practices of road safety measures among the motorbikers was not satisfactory although the majority of them knew individual signs and regulations. Therefore, this study suggests that education and strict enforcement of traffic rules may increase their knowledge and practice behaviour regarding road safety which in turn would minimise traffic injuries and fatalities.
- Safe Community
- Motorcycle
- Motor vehicle � Occupant
- Cross Sectional Study
Data availability statement
Data are available upon reasonable request. Data requests should be addressed to: asst.prof.bios@nipsom.gov.bd.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Motorbike injuries rank as the primary cause of fatalities and pose a significant public health concern in low- and middle-income countries including Bangladesh. Bangladesh holds the most concerning record of having the highest motorcycle death rate, with 28 fatalities per 10 000 motorcycles. But research on this issue is rare and not well-documented.
WHAT THIS STUDY ADDS
The involvement of motorcycles in road accidents and the number of casualties is increasing year by year in Dhaka, Bangladesh. To mitigate this growing public health crisis, the assessment of motorbikers’ perception and their adherence to these practices is crucial. This study aims to explore the knowledge and practices of motorbikers on road safety measures in Bangladesh through a cross-sectional study, and suggested some policy recommendations.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
As the overall good knowledge level and practices of road safety measures among the motorbikers were not satisfactory, this study suggests various policy recommendations such as educational training for drivers, Minimising under-reporting and well-documentation of data, developing a robust referral system and stringent regulations, knowledge and practices.
Introduction
Globally, road traffic injuries (RTIs) pose a serious threat to public health and are the leading cause of death among children, adolescents and young adults. Each year, around 1.3 million people die and about 20–50 million people suffer from traffic-related injuries that cost US$518 billion worldwide.1 Moreover, it is predicted to be the fifth leading cause of death2 and third leading cause of lost disability-adjusted life years by 2030.3 Worriedly, more than 90% of the fatalities occurred in low- and middle-income countries.1 Studies estimated that the traffic fatality rate in low- and middle-income countries is 20.2 deaths per 100 000 people, which is much higher than the rate in high-income countries (12.6 deaths per 100 000 people).4 According to a global assessment, around 46% of all traffic fatalities involve pedestrians, cyclists and riders of motorised two-wheelers, as well as their passengers.5 RTIs place a huge strain on healthcare services in terms of financial resources, bed occupancy and demand placed on health professionals.6 The WHO reported that Asia is the continent with the highest (6.5%) rate of motorcycle crash fatalities per 10 000 bikes.7 Six Asian nations such as Bangladesh, Cambodia, Laos, Thailand, India and Myanmar have fatality rates that are higher than the average road traffic crashes (RTCs) fatality rate of Asia.
From the last few years, Bangladesh has been facing numerous public health challenges including the outbreak of viral diseases (eg, COVID-19, Dengue), child and elderly nutritional needs and healthcare management.8–14 Along with this, the country has been noted for excessive RTC over the previous 5 years.15 According to the Passenger Welfare Association of Bangladesh reports, a non-government authority, more than 6000 people died each year for the last 8 years due to road crashes in Bangladesh which also injured over 100 000 individuals.16 However, this is not the clear picture since under-reporting is very common in countries like Bangladesh where a strong road traffic system is scarce. Surprisingly, the Bangladesh Road Traffic Authority (BRTA) started to publish reports on road injuries by themselves this year. Before that, only First Information reports (FIR) from police were counted as official cases.17 As a result, this impedes the Sustainable Development Goal’s target to reduce road traffic injuries and fatalities by half by 2030.
Similar to global road injury cases, motorcycle injury and fatalities have also been increasing in Bangladesh due to a dramatic rise in motorbike ownership. Motorcycles consisted of approximately 70% of all registered motor vehicles in the country with around 3.5 million.18 19 However, the authority issued only 22 million licenses which means a large number of unlicensed vehicles run on the road and this is direct evidence for a high rise in RTC by motorcycles. The most alarming fact is that Bangladesh is the country with the highest motorcycle death rate in the world, 28 per 10 000 motorcycles.20
RTIs in Bangladesh are multicause events that frequently result from many factors, including driver error, the state of the road and the condition of the vehicle.21 It poses a grave public health concern, leading to high mortality rates, injuries, financial loss and strain on the healthcare system.22 These results in significant loss of life, disabilities and economic burdens, affecting both individuals and the nation’s productivity. The psychological and social consequences, as well as the environmental repercussions, further compound the problem. To mitigate these challenges, Bangladesh has taken steps to improve road safety, developing infrastructure, and emergency response, but continued efforts are crucial to alleviate this pressing public health issue.
Methods and techniques for minimising the risk of a person using the road network, being killed or seriously injured are referred to as road traffic safety.23 The best practice of road safety strategies emphasises the preclusion of major injury and death crashes despite human fallibility.24 However, if drivers do not understand the information on safe driving behaviour that is encoded in the traffic signs, the signs will not be able to successfully perform their intended goals.25 Studies on how drivers interpret traffic psychological and demographic factors are still alarming.26 27
As previously described, motorbikes are the rising vehicles in Bangladesh, and RTCs is the predominant cause of death for individuals aged 15–29 years, the purpose of this study was to assess the level of knowledge and practice of road safety measures among motorbikers in Dhaka, the capital of Bangladesh. To the best of our knowledge, little research has been done on RTIs in Bangladesh in general22 28 29, and no study has been conducted on motorbikers. Therefore, the findings of this study would be helpful for motorbikers in increasing their knowledge and practice level regarding road safety. Moreover, it would be evidence for assisting the policy leaders to reappraise the policies regarding road safety and to devise appropriate action-based policies.
Methods
Ethical consent and permission for data collection
This study was approved by the institutional review board of the National Institute of Preventive and Social Medicine (NIPSOM), Bangladesh (Ref No: NIPSOM/IRB/2017/09). The declaration of Helsinki (revised version) was followed to conduct the study. Both written and verbal consent were taken before initiating the interview. A brief of the aims and objectives was given to the participants. Participants who agreed to give consent were finally included in the study.
Study setting and participants
This study was a cross-sectional study conducted by covering all the administrative wards of North and South City Corporation, Dhaka, from 1 January 2022 to 31 December 2022.
Sampling technique and sample size
Two-stage cluster sampling technique was applied in this study. In the first stage, all the major traffic points in Dhaka North and Dhaka South city corporation were listed and considered as clusters. In the second stage, 20 traffic points were randomly selected and motorbikers who gave consent were included in the study. The sample size of the study was calculated by using the formula below:
(1)
Here, n=assumed/desired sample size; z=the standard normal deviation; usually set at 1.96 at a 95% confidence level; p=percentage of practice is 17.6%=0.176, obtained by the literature search30; q=1 p; and d=Margin of error (5%) = 0.05.
Using equation 1, the sample size for the study when p=0.176 is
Initially, the study considered 223 participants as the required sample size. However, since no study was found that studied with a sufficient sample size, we additionally considered a usable 1.5 design effect and a 5% non-response rate. Finally, the sample size was 350.
Selection criteria
The inclusion criteria were: (1) Motor bikers who regularly ride a motorcycle; (2) male and aged 18 or above. And the exclusion criteria were bikers who have no authorised license to drive the motorbike.
Outcome measures
Respondents’ socio-demographic variables such as age, educational status and monthly income and their habits such as smoking behaviours and alcohol consumption patterns were considered independent variables. On the other hand, motorbikers’ knowledge and practice regarding road safety measures were dependent variables. These are presented in online supplemental table S1.
Supplemental material
Data collection tool and procedures
A structured questionnaire was used to collect data from the participants. Thirteen traffic signs provided by the BRTA and commonly used in the country were applied to assess respondents’ knowledge. We used 22 variables to assess bikers’ knowledge and 16 variables to assess their practice score regarding road safety measures. The average scoring technique was used in computation and their descriptive statistics including percentiles were observed. According to the percentile approach, the knowledge and practices were classified into three levels: poor (<25% percentile, score: <0.727); average (25–49% percentile, score: 0.727–0.817); and good (≥50% percentile, score: ≥0.818).31
Data quality control and statistical analysis
To ensure reliability and validity of the study results, we used a number of techniques: (1) conducted pretesting of our study, and revised the questionnaire (online supplemental table S2) by adding traffic sign and symptoms instead of just asking questions; (2) collected the data by a trained data collection team; (3) checked the data and fixed errors by observing descriptive statistics; (4) employed Cronbach’s alpha, the reliability coefficient which was moderately low (50 and 26); (5) employed updated version of statistical software in data analysis and (6) finally, we randomly re-observed the practice behaviours of motorbikers regarding road safety and signs (eg, their helmet wearing practice, right and left turning and safety sign instruction).
In data analysis, the descriptive statistics were performed first to present the socio-demographic characteristics and mean knowledge and practice scores of participants. To assess whether the knowledge and practice scores follow a normal distribution, we performed Kolmogorov-Smirnov and Shapiro-Wilk tests (online supplemental table S1), and observed the p values associated with these tests. Since both the knowledge and practice scores followed normal (PKolmogorov-Smirnov=<0.001; PShapiro-Wilk=<0.001), we performed an independent sample t-test and one-way analysis of variance test to show the mean knowledge and practice difference between two (eg, rural vs urban) and more than two (eg, different age groups) groups, respectively. A p value of 5% was considered significant at the 95% CI. All the analysis was performed in Microsoft Office-2019 and SPSS (V.26) software.
Results
Socio-demographic characteristics of the respondents
Table 1 shows the socio-demographic characteristics of the respondents. It was found that the majority of the respondents (42.86%) were aged between 30 and 39 years followed by respondents aged 18–29 years. Only 36.3% had completed tertiary education while 52% had secondary or higher secondary education. Almost half of the participants had a monthly family income of 20 000–30000 BDT (Bangladeshi taka). Moreover, the majority of them were engaged (67.7%), followed by service. Urban participants were more prevalent since the study covered participants from the capital city. While alcohol consumption was at the least (only 1%), the prevalence of smoking was high (61.7%) among participants.
Socio-demographic characteristics of the motorbikers in Dhaka city
Knowledge regarding road safety measures among respondents
Table 2 represents participants’ knowledge about road safety measures. Among the 350 respondents, more than 80% had knowledge on insurance policy while only 56.3% of them knew the maximum speed limit for driving in Dhaka city. Surprisingly, the ‘No stopping’ sign was unknown to about 80% of motorbikers, while about half of them did not know the 'Stopping’ sign. However, the majority of the respondents knew about the ‘No horn’ (98.6%), ‘U-turn’ (97.1%), ‘Zebra-crossing’ (94.3%) and ‘Speed breaker’ signs (85.4%). Moreover, almost all of them knew wearing a helmet and updating their documents is mandatory and drinking alcohol (98.3%), using mobile phones (98.3%), playing music ((96.6%), frequent overtaking (96.9%) and talking to others (92.3%) while driving is dangerous and/or prohibited (table 2).
Knowledge about road safety measures among respondents
Practice regarding road safety among respondents
Regarding good practices, the majority of the participants answered affirmatively regarding having insurance for their bikes (77.7%) and updating their licensing documents regularly (99.1%). Moreover, most of them followed road safety practices such as using a helmet (99.7%) and following the road speed limit while driving (91.4%) and being patient while pedestrians take time while crossing roads (96.0%). On the other hand, the majority avoided bad driving habits such as driving while drunk, using mobile phones and talking with others while driving. However, 88.3% of respondents practiced overtaking frequently while driving and over 60% were penalised by police for violating traffic laws (table 3).
Distribution of practice of road safety measures among motor-bikers
Overall knowledge and practice level of the respondents
Figure 1 depicts the level of average knowledge and practices of respondents and their association with educational status. It can be seen that only 54.5% had good knowledge, while 16.9% had poor knowledge (figure 1A). Similarly, only half of the respondents (50.6%) had a good practice level while 23.4% had a poor practice level (figure 1B).
(A) Distribution of overall knowledge level; (B) Distribution of overall practices level; (C) Association of knowledge with respondents’ educational status; (D) Association of practice with respondents’ educational status.
Higher knowledge levels and following good practices were associated with higher educational status (figure 1C,D). Approximately, over 55% of participants with secondary, higher secondary and tertiary education had good knowledge of road safety, while the majority of respondents with primary education had poor to average knowledge (figure 1C). Similarly, more than 50% of motorbikers who completed secondary, higher secondary and tertiary education followed good practices while most of the motorbikers with primary education did not follow good practices (figure 1D).
Variation in knowledge and practices of the respondents
A significant difference in respondents’ knowledge and practice with socio-demographic characteristics was observed (table 4). Results found that the average knowledge score was significantly higher among younger adults aged 18–29 years than that among the older population aged 50 and above (mean knowledge score: 0.80 (0.79–0.82) vs 0.75 (0.69–0.82); p=0.04). Similarly, the mean knowledge score was higher among participants with secondary, higher secondary and tertiary education compared with the primary education group. Moreover, knowledge score was higher among non-married (0.81 (0.79–0.83) vs 0.78 (0.77–0.79); p=0.006) and non-smokers (0.80 (0.79–0.82) vs 0.78 (0.77–0.79)); p=0.026] than their counterparts (table 4).
Independent sample t-test and one-way ANOVA test for knowledge and practice score
Regarding practices, the mean practice score was associated with educational status, religion and smoking status. Similar to knowledge level, the average practice score was higher among participants with secondary, higher secondary and tertiary education compared with the primary group. Additionally, average practice score was significantly higher (mean practice score: among Muslims (0.77 (0.77–0.78) vs 0.73 (0.69–0.77); p=0.025)).
Discussion
In Bangladesh, a significant increase in motorbike injuries created a healthcare burden that required urgent attention. Our study highlighted that despite increasing RTCs motorbikers lack adequate knowledge and are associated with poor road traffic practices. However, an increase in knowledge level was observed in young adults, higher education level, non-smokers and non-married respondents. Similarly, good practices were associated with education level and smoking status of the motorbikers.
Among our participants, the majority had insurance. Though the highest speed limit of vehicles in Dhaka is fixed, only 56.3% of the motorbikers knew the maximum speed limit for driving in Dhaka city while it has been observed that the highest number of motorbike and bike crashes occurs in Dhaka division.32 Majority of the respondents could recognise most of the signs such as ‘stopping’, ‘zebra crossing’, ‘u turn’ and ‘no overtaking’. However, only 20% of them could recognise the sign of ‘no stopping’ which is comparable to studies in other South Asian countries. A study in India reported that only 65.1% college students (aged 17–23) correctly identified the road signs while another study from Pakistan showed that 63.6% college students correctly identified the signs.33 In a study of Reang and Tripura, it was found that nearly 90% of respondents did not know about the ‘no stopping’ sign.34 Interestingly, the majority of motorbikers knew that wearing a helmet while driving is mandatory. Different studies found different results regarding wearing helmets, although nearly all countries mandate this law. For instance, a study in India by Jothula and Sreeharshika revealed that around 98% of respondents knew the law,35 while another study by Siviroj et al found that around 56% of motorbikers knew about the potential danger of not wearing a helmet.36 Similarly, over 90% of our study participants were aware that driving after drinking alcohol or using a mobile phone while driving is prohibited. Moreover, most of them knew that playing music, talking with others and overtaking frequently during riding are dangerous behaviours that could kill them. Compared with many other studies done in developing or least developed countries, respondents of this study were more aware of the laws. Jothula and Sreeharshika found that only 6.8% of the respondents of a study in India knew the permissible limit of alcohol.35 Similarly, Tajvar et al depicts that participants of their study believed that eating (49.8% agree) and drinking during driving are dangerous (34.9% agree).37
In accordance with the knowledge level, the majority of our participants followed good practices. The majority of the motorbikers wore helmets (99.7%) and followed the average speed limit (91.4%). Moreover, a small percentage of motorbikers reported driving after drinking alcohol (0.3%), using their phones (6.6%), playing music (4.6%) or talking with others (10.9%) while driving. Conversely, existing literature found a lower percentage of respondents wearing helmets. Jennissen et al found that 64% never wear helmets while driving.38 Furthermore, Wadhwaniya found that only 44.5%39 and Jothula and Sreeharshika found that only 25.9% of respondents wear helmets while driving.35 Helmets are recommended to prevent severe injuries and wearing helmets for motorbikers is a law in most countries. Studies found that it can minimise the risk of death to 42–69%.40 However, 88.3% of our participants reported overtaking frequently, although most of them knew it was dangerous. In comparison, only 44.4% of participants in an Iranian study performed overtaking practice. When it comes to young people, overtaking is one of the most dangerous37 manoeuvres they display frequently which causes a large number of injuries and fatalities. A German study depicts that around 6% of the injuries of which around 9% of deaths occurred in 2014 are due to overtaking practices.41 In addition to these, most of our participants (64.0%) were penalised by police at least once due to traffic violations which indicate their poor practice habits.
However, although the majority of our respondents could identify signs individually or reported being aware of some rules and regulations, their overall knowledge level of road safety was not satisfactory. Only 54.5% had good knowledge while the prevalence of poor knowledge was also noticeable. Likewise, as expected, only half of them followed good practices and a significant number of participants followed poor practices. Another similar study conducted by Baniya and Timilsina31 in Nepal showed that more than half (59.2%) of the respondents had moderately adequate knowledge.31 An interesting finding was that both knowledge and good practice levels were associated with respondents’ educational status.
Some socio-demographic factors were associated with both knowledge level and practices of road safety measures. The motorbikers’ knowledge score differs significantly among respondents with different educational levels, marital status and smoking behaviours. The knowledge level of participants with a higher secondary degree was significantly higher than people with other degrees. Although most of the world’s studies reported that the majority of road injuries and deaths involve young people aged between 20 and 29 years.42 Moreover, people who were married at any time and non-smokers tend to have higher knowledge scores. Although no studies reported these factors as contributing factors to increasing knowledge level, it is perceivable that people who are married and non-smokers tend to be more aware and conscious regarding life. Education levels were also found to be a contributing factor in higher practice scores as participants with higher secondary degrees had a significantly higher score than people with other degrees. Moreover, significantly higher practice scores were observed in Muslims and non-smokers. A study by Bachani et al43 found that educated persons have a lower chance of being smokers than uneducated ones. As the majority of the respondents included in the study were educated, thus the majority were non-smokers and had good knowledge and followed good practices on road safety measures.43
Recommendations and future directions
RTIs have become one of the major health concerns worldwide which constituted about 11% of the global burden of disease in 2015.44 According to the WHO, the annual mortality rate due to road crashes per capita in Bangladesh is twice the average rate in developed countries, and is the highest in South Asia.45 Although the government of Bangladesh enforces ‘No licence, no bike’ rules, it is far behind in achieving the target of the Sustainable Development Goals of reducing the number of injuries and deaths by half by 2030. Hence, urgent attention is needed to tackle this silent public health threat.
Proper training for drivers
Bangladesh Road Transport Authority, the sole authority providing driving licences should arrange training or educational campaigns on road safety measures. Currently, they provide training on only driving and upgrading vehicles. Many countries introduced ‘Road Safety Education’ programmes that considerably reduced morbidity and mortality.46 However, it was also observed that the effects of many of these interventions did not sustain for a long time47 and hence, training or campaigns need to be arranged quarterly or half-yearly.
Minimising under-reporting
Under-reporting is another concern for least-developed countries like Bangladesh that prevent people from perceiving the true magnitude of road injuries. While the authority estimated annual road crash-related deaths in 2015 was 2538, the WHO estimated the number may range from 20 736 and 21 316.48 Therefore, the authority should take every case into account and publish true reports publicly that would facilitate mass awareness.
Develop a robust referral system
Like many middle and low-income countries, Bangladesh lacks a robust referral system that includes health risk and hazard assessment and direct medical costs. Severe injuries could lead to death when urgent treatment is not available. A comprehensive referral system comprises differentiating severe cases, timely transportation, prompt communication between facilities and immediate care at treatment facilities. Policymakers, public health experts, non-governmental advisory organisations and leaders of vehicle owners’ associations should work collaboratively to devise an effective scheme.
Stringent regulations and awareness
The government could initiate road safety education at school and college levels since road injuries are more common among adolescents and teenagers. All drivers should be licensed and their data should be stored with the authority so that nobody can avoid punishment if involved with a major injury. Finally, it is more of a self-responsibility to comply with good safety practices.
Conclusion
The overall knowledge and practice behaviour of motorbikers was not satisfactory. Higher education and quitting smoking during the drive were the significant factors that contributed to increased knowledge and good road safety practice. The findings of the study are important for the authority and policymakers of Bangladesh to develop pragmatic road safety contrivances that would considerably reduce morbidity and mortality, and help achieve targets of Sustainable Development Goals.
Abstract translation
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.Data availability statement
Data are available upon reasonable request. Data requests should be addressed to: asst.prof.bios@nipsom.gov.bd.
Ethics statements
Patient consent for publication
Ethics approval
This study was approved by the institutional review board of the National Institute of Preventive and Social Medicine (NIPSOM), Bangladesh (Ref No: NIPSOM/IRB/2017/09). The declaration of Helsinki (revised version) was followed to conduct the study. Both written and verbal consent were taken before initiating the interview. A brief of the aims and objectives was given to the participants. Participants who agreed to give consent were finally included in the study.
Acknowledgments
We acknowledge the department of biostatistics for their technical support during the study. We are also grateful to all participants included this study.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Twitter @meshbah037
Contributors Conceptualisations: MMR, HS and SKD. Formal analysis: SKD and MMR. Investigation: SKD, TT, AN and MMR. Methodology: SKD and MMR. Project administration: SKD, AAN, SKK, HS, BKR, ASI, GS and MMR. Supervision: MMR. Validation: HS, BKR, ASI, GS, BKD and MMR. Visualisation: SKD, AAN, SKK and MMR. Writing—original draft: SKD, TT, AN, AAN, PD, SKK, BKD and MMR. Writing—review and editing: SKD, TT, AN, AAN, PD, SKK, HS, BKR, ASI, GS, BKD and MMR.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.