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Abstract
Background The use of non-standard motorcycle helmets has the potential to undermine multinational efforts aimed at reducing the burden of road traffic injuries associated with motorcycle crashes. However, little is known about the prevalence or factors associated with their use.
Methods Collaborating institutions in nine low- and middle-income countries undertook cross-sectional surveys, markets surveys, and reviewed legislation and enforcement practices around non-standard helmets.
Findings 5563 helmet-wearing motorcyclists were observed; 54% of the helmets did not appear to have a marker/sticker indicating that the helmet met required standards and interviewers judged that 49% of the helmets were likely to be non-standard helmets. 5088 (91%) of the motorcyclists agreed to be interviewed; those who had spent less than US$10 on their helmet were found to be at the greatest risk of wearing a non-standard helmet. Data were collected across 126 different retail outlets; across all countries, regardless of outlet type, standard helmets were generally 2–3 times more expensive than non-standard helmets. While seven of the nine countries had legislation prohibiting the use of non-standard helmets, only four had legislation prohibiting their manufacture or sale and only three had legislation prohibiting their import. Enforcement of any legislation appeared to be minimal.
Interpretation Our findings suggest that the widespread use of non-standard helmets in low- and middle-income countries may limit the potential gains of helmet use programmes. Strategies aimed at reducing the costs of standard helmets, combined with both legislation and enforcement, will be required to maximise the effects of existing campaigns.
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Introduction
Globally, road traffic crashes result in over 1.2 million deaths and between 20 and 50 million non-fatal injuries each year.1 Motorcyclists comprise between 5% and 18% of road traffic injury deaths in high-income countries;2 however, in many low- and middle-income countries, they comprise a significantly higher proportion. In Thailand and Indonesia, for instance, motorcycle fatalities account for 70% and 55% of total road fatalities, respectively.1 Motorcyclists are at a greater risk of injury than other road users. In Singapore while motorcyclists account for 17% of all motorised vehicles they account for 48% of all road fatalities, and in most other countries in the Western Pacific Region there is an over-representation of fatalities among motorcyclists relative to the size of their motorcycle fleets.3 ,4
Head injuries account for around 75% of deaths among motorised two wheelers in European countries, while in low- and middle-income countries this figure is estimated at up to 88%.5 ,6 Wearing a motorcycle helmet has been shown to decrease the risk and severity of injuries by about 72%, decrease the likelihood of death by up to 39%, and decrease the healthcare costs associated with a crash.7 Adopting and enforcing legislation on helmet use has been shown to lead to an increase in wearing rates and can provide a cost effective way of reducing traffic-related injuries and deaths.8 ,9 Accordingly, most high-income countries and a number of low- and middle- income countries have adopted legislation requiring the use of helmets.2
The effectiveness of this legislation is, however, likely to be contingent in part on the quality of the helmets being used. It is questionable whether non-standard helmets that do not meet regulatory standards offer the same degree of protection as standard helmets. Indeed, there is some evidence to suggest that non-standard helmets might be associated with a higher prevalence and greater severity of head injuries than both riders wearing standard helmets and riders not wearing any head protection.10 In a large part, this is likely to be due to the lower quality of impact-absorbing lining of helmets that do not meet national and international standards.11
There is some limited evidence to suggest that non-standard helmets are increasingly being used in many low- and middle-income countries. For instance, a study carried out in the Guangxi region of China suggested that two-thirds (66%) of motorcyclists were wearing non-standard helmets12 and a study in Vietnam found that only 4.4% of helmets complied with all the requirements of the mandated helmet standard.13 However, the extent to which non-standard helmets are actually being used in low- and middle-income countries has not been widely documented and thus the real extent to which the use of non-standard helmets represents a public health problem is uncertain.
Likewise, there is limited information on the cost differentials between standard and non-standard helmets. While the recent Global Status Report on Road Safety showed that helmets standards were lacking in 43% of countries,1 information about legislative and enforcement practices relating to their manufacture, import and sale was limited. The objectives of the present study, therefore, were to determine the prevalence and determinants of non-standard motorcycle helmet use among helmet-wearing motorcyclists in nine low- and middle-income countries, to compare the prices of standard and non-standard helmets, and to ascertain the existence and enforcement of relevant legislation.
Methods
Under the auspices of the Road Traffic Injuries Research Network—an initiative aimed at reducing road traffic injuries in low- and middle-income countries (http://www.rtirn.net)—and with the support of a study coordinating centre at the University Putra Malaysia, collaborators in nine countries participated in this study: China, Ghana, India, Malaysia, Mexico, Nigeria, Pakistan, Thailand and Vietnam. Each collaborating centre undertook a cross-sectional survey of helmet-wearing motorcyclists, a market survey of helmet prices, and a review of current legislation and enforcement policies and practices. The study design and protocol, data collection instruments and analyses were developed by the collaborating partners. Data collection was undertaken between May 2008 and May 2009 and all collaborating sites obtained ethical approval from their local ethics committees.
Cross-sectional survey
The cross-sectional survey sought to obtain information from a random sample of helmet-wearing motorcyclists. In each country, a random sample of helmet-wearing motorcyclists (drivers and passengers) stopping at petrol stations within a defined urban area was recruited. A central location such as the town hall was nominated, and the closest petrol station to this location was identified. Consent from petrol station owners/managers was sought and if not provided, the next closest petrol station was recruited.
All motorcyclists—drivers and passengers—stopping to purchase petrol and wearing a helmet were eligible for participation in the survey. In heavy traffic volume petrol stations, a sampling selection was employed that selected the next available motorcyclist once an interview was completed. To maximise the safety of study staff, recruitment was undertaken on week days and in daylight hours. A minimum of 500 respondents were sought from each site to ensure that there were sufficient numbers to enable comparisons between those wearing standard and non-standard helmets (based on previous studies suggesting that as few as 4% of motorcycle wearing helmets might be wearing standard helmets13).
After informing potential respondents of the purpose of study and obtaining verbal consent, the trained interviewers used a standardised, questionnaire (pilot-tested in all nine countries) to collect demographic information about the participating motorcyclists, information about their helmet (ownership, purchase, purchase price and the factors influencing their purchase) and vehicle ownership as well as the purpose of their current trip. In addition, the interviewers recorded whether they observed a certification marker/sticker (indicating that the helmet met required international, national or local standards); their views on the authenticity of the marker/sticker; their opinion as to whether the helmet was a standard helmet, and if not, their reasons.
Interviewers were given prior training to differentiate between standard and non-standard helmets and also to differentiate between authentic and non-authentic markers/stickers. Specifically, they were shown and examined examples of both standard and non-standard helmets and authentic and non-authentic stickers. However, to maximise the reliability and validity across sites, ‘non-standard’ helmets were simply defined as those helmets that were designed for another purpose (such as for construction work); those that were cracked or damaged; and those that had no certification marking.
Interviewers also recorded their observations about the size of the motorcycle, the gender of the respondent, whether he/she was a driver or passenger and the number of individuals travelling on the motorcycle. This observational information was recorded both for respondents agreeing to participate in the interview and those not agreeing.
Interviews and paper questionnaires were in the language relevant to each collaborating centre. However, responses were translated into English and entered into a web-based electronic data entry system managed by The George Institute for Global Health in Sydney. Inbuilt checks ensured that only relevant information was captured in the system and data queries were generated automatically for any anomalies that were identified.
Analyses were undertaken following an agreed, predetermined plan by the coordinating centre in Malaysia. Data were analysed using SPSS V.17. Descriptive statistics on the study population were produced as well as information on the prevalence of non-standard helmet use. Further analyses involved using logistic regression to examine the association between the independent variables and the use of non-standard helmets. Specifically, all independent variables were examined in the initial univariate analyses and those variables that were shown in these analyses to be associated with non-standard helmet use (p<0.05) were included in the multivariate analyses. Forward stepwise (likelihood ratio) binary logistic regression was used to select the significant contributing variables to non-standard helmet use.
Market survey
In each of the previously identified urban areas, the market survey sought information on helmet costs from a convenience sample of different types of retail outlets: shops selling only automobile or motorcycle and related products; general shops and supermarkets; informal road vendors or small roadside shops; and other outlets. Three or more outlets were sought from each of the first three categories, such that a minimum of nine outlets were to be included from each of the study sites. After obtaining oral or written consent to participate in the survey from the retailers, interviewers sought information on the maximum and minimum costs of standard and non-standard helmets available for purchase, as well as the prices of the most commonly sold standard and non-standard helmets. Determination of ‘standard’ versus non-standard helmet status was based on the criteria used in the cross-sectional survey. Information was collected in local currency and in local languages. However, all costs were converted to standard US dollars using the exchange rates at the time of data collection, and responses were translated into English. Data were sent to the coordinating centre in Malaysia and analyses were undertaken using an agreed, predetermined plan.
Review of legislation and enforcement
At each of survey sites, information on relevant legislation, enforcement policies and existing practices was sought in relation to the manufacture, import, sale and use of non-standard motorcycle helmets. A standardised data collection format was used to collect summary information on relevant legislation and where legislation existed and on relevant enforcement policies. Where such enforcement policies existed, data were then sought on the numbers of documented citations/offences for the relevant urban site and for the most recent 12-month period. A standardised data collection instrument was again used to collect this information. Data were sent to the coordinating centre in Malaysia for collation and analysis using an agreed, predetermined plan.
Role of the funding source
The study sponsors played no role in the study design, collection and analysis of information, and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication.
Results
Cross-sectional survey
In total, 5563 helmet-wearing motorcycle drivers and passengers were invited to participate in the survey and observations were made on all 5563 motorcyclists (table 1). The largest sample was from China (n=1120) and the smallest from Mexico (n=413). Most (81%) of the 5563 motorcyclists were male subjects, with riders comprising 95% of the motorcyclists. Most (80%) were riding motorcycles that were between 100 and 500 cc, with almost all the others (20%) riding smaller vehicles and most of the motorcycles (80%) had only one rider.
Demographic and other non-helmet variables in nine countries
Consent and information was obtained from 5088 (91%) of this sample (table 1) with response rates ranging from 100% in Mexico to 79% in India. Most (94%) were less than 50 years of age and 25% were aged 25 years or younger. Almost 40% of respondents had received postschool education, with an additional 47% having received secondary schooling. The large majority (87%) owned their motorcycle; 64% were travelling to or from work at the time of the survey; and another 19% were using their motorcycle for commercial activity.
Most (93%) of the 5088 respondents owned their helmets (table 2). The majority (61%) had purchased their helmets from a specific motorcycle/helmet shop, with 15% purchasing from a street market vendor, and another 11% from a general shopping centre. However, street market vendors accounted for a sizeable proportion of sales in some countries: 35% of helmets in Ghana and 24% of helmets in both Pakistan and Vietnam. Helmet costs varied from less than US$5 (21% of respondents) to more than US$20 (18% of respondents). The most commonly reported factor influencing purchase was helmet quality (reported by 49% of respondents) followed by price (34%) and style/look (31%).
Helmet variables in nine countries
Of the 5563 helmets that were observed, 54% did not have a certification marker/sticker; of the 46% for which a marker/sticker was observed, 19% were rated as not authentic since it did not carry specifications of the national or local standard (table 2). However, in Pakistan this proportion was notably higher, with 22% being judged as not authentic. The interviewers judged that overall 49% of the helmets were likely to be non-standard helmets. This proportion varied considerably between study sites, ranging from 79% in China to 13% in Thailand. Over a quarter (26%) of the helmets judged to be non-standard were designed for purposes other than motorcycle use (such as construction helmets), and 20% were judged to be non-standard because they were cracked or damaged.
In multivariate analyses, six factors were associated with an increased risk of being judged to be wearing a non-standard helmet (table 3): male subjects, riders with less than postschool education, riders engaged in commercial activities or driving for pleasure, those riding with passengers, those not owning their motorcycle, and those spending less than US$20 on their helmet. Those spending less that US$10 on their helmet were at the greatest risk.
Factors associated with non-standard helmet use: multivariate analyses
Market survey
Across the nine sites, data were collected from 126 outlets: 84 (67%) of the outlets were motorcycle specialist shops, 15 were general shops or supermarkets, 24 were informal road vendors and three (motorcycle repair shops) were classified as ‘others’. Cost ratios could not be derived for Thailand and Vietnam as no non-standard helmets were available for purchase in the sites surveyed. In all other survey sites, regardless of the type of outlet, standard helmets were between two and three times more expensive than non-standard helmets (table 4).
Cost ratios of non-standard to standard helmets
Review of legislation and enforcement
Only four of the nine countries reported legislation prohibiting the manufacture of non-standard helmets (table 5). Of these, three reported enforcement policies, with only Thailand recording information on any offences or convictions in the previous year for which data had been recorded. Three countries reported legislation and enforcement policies prohibiting the import of non-standard helmets, but in only Vietnam had offences had been recorded. Legislation and enforcement policies prohibiting the sale of non-standard helmets were reported for four countries, with data on offences available for Thailand and Vietnam. Seven of the nine countries (excluding Mexico and Pakistan) reported laws prohibiting the use of non-standard helmets. While six of these also reported policies on enforcement, no country provided any data to suggest that offences had been reported (table 5).
Existence of legislation and its implementation: manufacturing, import, sale and use of non-standard helmets
Discussion
Increasing motorisation in many low- and middle-income countries and recognition of road traffic injuries as a major public health problem are leading to countries enacting or strengthening helmet legislation to reduce motorcycle injuries. However, our study suggests that about half the helmets being used may be non-standard helmets and that the lower costs of these helmets is the most significant factor associated with their use. While quality is a relevant factor in purchase considerations, price is also an important factor. Given the almost threefold difference in price between non-standard and standard helmets found in our markets surveys, it is not surprising, therefore, that there is a strong financial incentive for motorcyclists to buy non-standard helmets over higher quality helmets. Conversely, the relative absence of enforced legislation specific to non-standard helmets provides few disincentives to the purchase of cheaper and poorer quality helmets.
Our estimate of the prevalence of use of non-standard helmets is based in a large part on the observation of certification marking. This is perhaps the most reliable way in which both motorcyclists/purchasers and law enforcement officials can ensure that helmets meet recognised standards. However, reliance on this measure for the purposes of our study may have led in some cases to an overestimate or an underestimate of the use of non-standard helmets. In some countries, such as Ghana, certification markers are not required and in some other countries, they are not required to be shown on the outside surface of the helmet. Consequently, the observed absence of a marker may have led to an overestimate of the prevalence of non-standard helmets. However, not all markers that were observed were judged to be authentic, with almost a third of those in Pakistan considered in this category. Consequently, in some settings it is likely that the prevalence estimates were underestimated. Nevertheless, as over a quarter of all helmets were deemed to have been designed for purposes other than motorcycling, our findings suggest that, even in the absence of truly reliable data, the use of non-standard helmets is significant.
While our study was limited to nine low- and middle-income countries, our findings are likely to be relevant to other emerging economies. The selection of motorcyclists from petrol stations arguably provides a reasonable ‘capture’ of a random sample of motorcyclists, given that all motorcyclists will need to stop to refuel; additionally, observations were made on all the helmeted motorcyclists surveyed and the response rates obtained were extremely high (between 80% and 100%). However, as the surveys were conducted in urban areas only, the findings might not be extrapolated directly to rural areas.
The key finding from the market surveys, suggesting that non-standard helmets are significantly cheaper than standard helmets, is likely to be mirrored in other low- and middle-income countries, given that our findings were consistent across all the participating countries. Similarly, information obtained on legislation, enforcement policies and practices might well reflect the situation in other countries. Indeed, our findings on legislation relating to the use of non-standard helmets are consistent with those in the recent Global Status Report on Road Safety: of 127 low- and middle-income countries, only 43% required motorcyclists to use helmets meeting a national or international standard.1 However, the extent to which the documented information on offences truly represents the numbers of violations of the legislation seems doubtful, given, for example, the observed use of non-standard helmets in a number of countries where legislation against their use existed. We think it more likely that this reflects the poor enforcement of this legislation.
In summary, while the recent enactment and enforcement of mandatory motorcycle helmet laws in low- and middle-income countries has been shown to increase helmet usage and decrease the likelihood and severity of head injuries,14 our findings suggest that the widespread use of non-standard helmets has the potential to minimise the gains of this legislation. Consequently, we strongly recommend that as mandatory helmet laws are introduced, they are introduced in conjunction with relevant legislation and enforcement pertaining to standards. The establishment of national regulatory bodies to oversee the manufacture, import, certification and sales of motorcycle helmets might assist in this regard. Concurrently, governments need to explore pricing options for standard helmets that reduce cost differentials between standard and non-standard helmets: this may include subsidisation programmes that provide incentives for the manufacture and purchase of standard helmets or methods to reduce the costs associated with manufacture of standard helmets. Equally important will be the need to increasing community awareness of the association between using a standard helmet and the quality and effectiveness of the helmet in reducing the risk of motorcycle injury and disability.
What is already known on this subject
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Motorcyclists comprise a high proportion of road traffic injury deaths in low and middle-income countries.
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Large proportion of that in LMIC and increasing in parts of Asia and Africa.
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Adopting and enforcing legislation on helmet use leads to increasing use of helmets and reductions in deaths.
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Helmet usage is a challenge and risk factor for head injuries.
What this study adds
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Documented evidence on the prevalence of non-standard helmets in low and middle-income countries.
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First multi-country analysis of non-standard helmet use.
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Documentation of the prevalnce of non-standard helmets and their availability.
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Cost data showing the substantially lower purchase prices of non-standard helmets.
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Information showing the paucity of legislation and enforcement strategies relating to non-standard helmets.
Acknowledgments
We would like to thank all the study teams and Dr Tami Toroyan from WHO for the support provided in the development of this work.
Footnotes
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Contributors AG, GG, AH, MH, RN, WO, MP, SK, RMRS conceived and designed the study. SK, RN, AH carried out the statistical analyses, interpreted the data and drafted the paper. JY, FA, WA, WA, GG, SK, KY, KR, HAR, EH, MH, CI, EO, AS, JAR, JS, NV, MV, NVV, PLT, TTA and NTVA collected the data and revised critically the document for important intellectual content. All authors approved the final version. Coordinating Centre: Road Safety Research Centre, University Putra Malaysia: SK, Road Traffic Injuries Research Network Board and Study Executive Committee: AG, Global Forum for Health Research, Geneva. GG, National Institute of Mental Health and Neuro Sciences, India. MH, National Institute of Public Health, Mexico. AAH, Johns Hopkins University Bloomberg School of Public Health, USA. RN, The George Institute for Global Health, University of Sydney, Australia. WO, Moi University, Kenya. MP, Department of Violence, Injury Prevention and Disability, WHO, Geneva. RMRS, Malaysian Institute of Road Safety Research, Malaysia.
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Funding This study was funded by the Road Traffic Injuries Research Network (http://www.rtirn.net) using funds granted by the World Bank's Global Road Safety Facility, and WHO's Department of Violence, Injury Prevention and Disability (http://www.who.int/violence_injury_prevention). During this time, the Global Forum for Health Research provided core funding support to the Road Traffic Injuries Research Network. This study was funded by the Road Traffic Injuries Research Network using grant support from: the World Bank's Global Road Safety Facility, WHO's Department of Violence, Injury Prevention and Disability, and the Global Forum for Health Research.
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Competing interests None.