- Email: [email protected]
Perceptions regarding helmet use: a cross-sectional survey of female pillions in Karachi, Pakistan
j o u r n a l o f s u r g i c a l r e s e a r c h - 2 0 1 6 ( - ) 1 e5
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Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Q1
Q8
Q3
Perceptions regarding helmet use: a cross-sectional survey of female pillions in Karachi, Pakistan Maryam Saeed, MBBS,a Selma Marie Siddiqui, MD,b,* Uzma Rahim Khan, MBBS, MSc,a and Mamta Swaroop, MD, FACSc a
Aga Khan University, Karachi, Pakistan School of Medicine, Johns Hopkins University, Baltimore, Maryland c Feinberg School of Medicine, Northwestern University, Chicago, Illinois b
Q5
article info
abstract
Article history:
Background: In 2011, road traffic injuryeassociated fatalities among motorized two-wheeler
Received 22 July 2016
(MTW) pillion riders (backseat two-wheeler passengers) rose 30% in Karachi. Despite
Received in revised form
mandatory helmet laws, helmet use fell 20% the same year. This study aims to identify
8 November 2016
opinions of female pillions on helmet usage and whether various forms of media influence
Accepted 30 November 2016
their self-perception.
Available online xxx
Methods: Trained surveyors, using a survey tool used in similar studies in South Asia, conducted random, man-on-the-street interviews of 400 women in four areas of Karachi.
Keywords:
Data pertaining to demographics, opinions on helmet laws, media influences, and
Pillion riders
helmet usage were collected. Data were analyzed in SAS 9.3 using chi-squared or Fisher’s
Motorized two wheeler
exact tests.
Karachi
Results: Of the 400 women, 98.8% (n ¼ 394) reported never wearing a helmet while riding on
Pakistan
a MTW as a pillion rider. Women with a postsecondary or higher (US ninth grade)
Helmet use
education level were more likely to be aware of helmet laws (38.6%) than women with lower education levels (24.6%, P ¼ 0.005). Most women (82.4%, n ¼ 329) supported mandatory laws and 97% (n ¼ 289) recognized that disability was the more likely to result than death in event of a traumatic brain injury. Nearly all (98.5%, n ¼ 394) stated that they would use a helmet if they were men, regardless of age, education level, or employment status. Television news was the most influential media form (83.7%, n ¼ 334), with most women finding it effective because of its informative nature (91.3%, n ¼ 303). Conclusions: Most Pakistani women do not personally use helmets when riding MTWs, yet most believe helmet use should be legally required for MTW riders and drivers. These data show that media outlets such as television can be used as a platform to educate the public about helmet usage, which may lead to improved helmet compliance among female MTW pillions in Pakistan. Furthermore, investigations into improved helmet comfort and appearance by collaborating with helmet manufacturers may have a positive impact on helmet use in Pakistan. ª 2016 Elsevier Inc. All rights reserved.
This work was presented at the AAS February 2014 Academic Surgical Congress. * Corresponding author. School of Medicine, Johns Hopkins University, Surgery 600 N. Wolfe Street, Osler 603, Baltimore, MD 21287. Tel.: þ1 9199619568 (Mobile); fax: þ1 9199619568. Q4 E-mail address: [email protected] (S.M. Siddiqui). 0022-4804/$ e see front matter ª 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2016.11.063
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131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195
j o u r n a l o f s u r g i c a l r e s e a r c h - 2 0 1 6 ( - ) 1 e5
Introduction According to the World Health Organization’s (WHO) Global Road Safety Report 2015, approximately 1.25 million people die annually as a result of road traffic crashes. Half of these crashes involve “vulnerable road users” including pedestrians, cyclist, and motorcyclists. Motorized two wheelers (MTWs) are the most prevalent mode of transportation in lowand middle-income countries. However, because of minimal safety features, they are statistically more likely to be involved in serious accidents.1 In China, motorcycle ownership between year 1987 and 2001 grew rapidly from 23% to 63%, with a corresponding increase in the proportion of traffic fatalities sustained by motorcyclists rising from 7.5% to 19% over the same period.2 This trend is seen across South and South East Asia, with the proportion of MTW-associated road accident fatalities ranging from 27% in India,3 60% in Malaysia,4 and between 60% and 90% in Thailand.5 Pakistan, a developing country of 182 million people,6 has more than 9 million registered vehicles, 61.2% of which are two- or three-wheeler vehicles. According to the WHO’s report, 7636 road traffic injury (RTI)-associated fatalities were reported from Pakistan in 2013.7 However, underreporting skews, these numbers such that the WHO estimated an actual 25,781 RTI-associated fatalities, most of which involved twoand three-wheeler vehicles. The Road Traffic Injury Research and Prevention Center is an organization based in Karachi, Pakistan, that is actively involved in surveillance of RTIs in Karachi. According to data they collected in 2013, there were 1130 fatalities that year with 51% of those being MTW drivers and pillion (backseat MTW passenger) riders.8 Helmets are considered the primary mode of protection against head injuries with regards to MTW, reducing the risk of death by 42% and the risk of head injury by 69%.9 These data strongly support the use of helmets, and Pakistan has passed legislation mandating helmet use for all MTW riders. However, empirically compliance with these laws remains low, and helmets are rarely used by female pillion riders. Studies in culturally similar neighboring India have shown a low helmet compliance rate among female pillion riders despite the existence of a mandatory helmet law. Our study aims to determine the attitudes of female pillion riders regarding helmet usage and determine whether various media outlets influence these perceptions. We hypothesize that most women will not be aware of Pakistan’s existing helmet laws. We also hypothesize that most women will report that television media outlets are influential on their helmet use habits.
adjusted to improve internal validity. These 15 surveys were not included in the data set for analysis. Five trained survey administrators completed 400 surveys at four popular shopping centers in Karachi, Pakistan: Gulf Shopping Center, Tariq road, Saddar Bazaar, and Meena Bazaar. These were chosen because of their heavy volume of female pedestrian traffic. Females aged 18 y were included for survey administration, and females aged <18 y were excluded. A verbal consent was obtained before the interview. The survey was administered in a face-to-face interview in Urdu, whereby trained survey administrators read the questions for the respondents and recorded the responses on paper. No identifying information from respondents was queried or recorded. The collected responses were entered into Microsoft Excel (Microsoft Corporation, Redmond, WA). Similar themes among the open-ended answers were identified, and the responses were grouped into these themes categories for analysis. The data were analyzed in SAS version 9.3 (Cary, NC), and Microsoft Excel Comparisons of respondents’ use of helmets and beliefs regarding helmet and head injuries were made using chi-squared and Fisher’s exact tests. The Ethics Committee of Aga Khan University Hospital approved this study.
Results All 400 surveys were completed in Urdu. Several forms were partially completed; completed responses from these surveys were included in our analyses.
Table 1 e Survey population demographics (n [ 400). n
%
25
138
34.5
26-40
180
45
41
82
20.5
Working
127
31.7
Not working
273
68.2
Married
269
67.2
Unmarried
131
32.7
20
5.0
Age (y)
Employment
Marital status
Education* None High school
Methods A survey was developed in English comprising of 25 multiplechoice questions with each question followed by an openended query (Appendix 1). The survey included questions regarding demographics, opinion on helmet laws, media influences, and helmet use. A trained bilingual survey administrator translated the survey from English to Urdu. The sample survey was tested on 15 random individuals, and the survey was
231
57.9
University
99
24.8
Advanced degree
49
12.3
365
91.3
Hindu
13
3.3
Christian
22
5.5
Religion Muslim
*
Because of respondent omission, education level is reported for an n of 399 respondents rather than 400.
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196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260
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261 262 263 264 265 266 267 268 269 270 271 272 273 274 275 276 277 278 279 280 281 282 283 284 285 286 287 288 289 290 291 292 293 294 295 296 297 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322 323 324 325
Self-reported demographics of the women surveyed are listed (Table 1). Of the 400 women surveyed, 98.8% (n ¼ 394) had never worn a helmet while riding on a MTW as a pillion. When asked about their reasons for not using a helmet, 29.2% (n ¼ 113) cited appearance as the primary reason. Lack of legal mandate necessitating helmet use was the next most common reason, cited by 26.2% (n ¼ 102), followed by the belief that helmets are ineffective in case of a road traffic crash (Table 2). When asked if they knew about laws related to helmet use, 33% (n ¼ 132) acknowledged being aware of laws mandating helmet use for both the driver and pillion rider(s), whereas 64.5% (n ¼ 248) were unaware of the existence of such laws. Women with a postsecondary or higher (US ninth grade) education were more likely to be aware of helmet laws (38.6%) than women with less education (24.6%, P ¼ 0.005; Table 3). Most women, 83.2% (n ¼ 329), affirmed that there should be strict laws requiring female pillion riders to wear helmets (Table 4). Regardless of age, level of education, or employment status, 98.5% of women (n ¼ 394) reported that they would wear a helmet if they were male riders. Safety was cited as the main reason for using a helmet by 63.2% (n ¼ 249). Nearly all the women surveyed (97%, n ¼ 289) felt that a disability would occur more frequently than death in the event of a traumatic brain injury (Table 5). Respondents were asked whether various forms of media influence their behavior and attitudes with 83.7% (n ¼ 334) of women citing television news as influential on their behavior patterns (Table 6). Most women, 91.3% (n ¼ 303), found television news effective because of its informative nature. When asked whether religious affiliation influenced their attitudes and behaviors, most women (96.8%, n ¼ 387) believed that religious groups had a considerable influence on their behavior.
Discussion Karachi, the financial capital of Pakistan and its largest city, reported 9000 RTIs among MTW drivers and pillion (backseat MTW passenger) riders in the year 2009. According to the Road Traffic Injury and Research Prevention Center, >95% of drivers
Table 2 e Reasons for helmet disuse while riding pillion (n [ 397). Reasons reported
n
%
Appearance
116
29.2
No legal mandate
104
26.2
33
8.3
Never thought about it No need
32
8.1
Nobody uses it
30
7.6
Discomfort
22
5.5
Other*
60
15.1
*
These responses included things such as helmets are ineffective, helmets cannot be used with scarves and head coverings, helmets interfere with children on lap, and helmets are not available in women’s sizes.
Q7 326
Table 3 e Is there a helmet law in place? (n [ 400). Yes, % (n ¼ 132)
No, % (n ¼ 259)
Do not know, % (n ¼ 9)
P value
Secondary or less
24.6
71.5
3.7
0.005
Postsecondary
38.5
59.4
1.2
Yes
28.3
68.5
3.1
No
35.1
63
1.8
Yes
34.5
63.1
2.2
No
29.7
67.9
2.2
Muslim
32.8
64.9
2.2
Hindu
30.7
61.5
7.6
Christian
36.3
63.6
0
<25
29.7
67.3
2.9
26-40
35
63.3
1.6
>41
34.1
63.4
2.4
Education level
Employed 0.31
Married 0.62
Religion 0.59
Age (y) 0.80
and pillion riders involved in these incidents were not wearing safety helmets. Despite the presence of mandatory laws, helmets use remains low, especially among pillion riders.10 A cross-sectional observational study in China revealed that the rate of correct helmet use was a mere 20.9% across all pillions.11 A similar study conducted in New Delhi, India, in
Table 4 e Should women pillion riders be legally mandated to use helmets? (n [ 400). Yes, % (n ¼ 329)
No, % (n ¼ 67)
Not sure, % (n ¼ 3)
P value
Secondary or less
79.1
20.2
0.63
0.24
Postsecondary
85
14.1
0.83
Education level
Employed Yes
85
14.1
0.7
No
81.2
18
0.7
Yes
80.2
19
0.74
No
87
12.2
0.76
Muslim
81.8
17.3
0.82
Hindu
69.2
30.7
0
0
0
0.62
Married 0.18
Religion
Christian
100
0.07
Age (y) <25
82.4
17.5
0
26-40
80.5
17.7
1.6
>41
86.5
13.4
0
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Q2
0.50
327 328 329 330 331 332 333 334 335 336 337 338 339 340 341 342 343 344 345 346 347 348 349 350 351 352 353 354 355 356 357 358 359 360 361 362 363 364 365 366 367 368 369 370 371 372 373 374 375 376 377 378 379 380 381 382 383 384 385 386 387 388 389 390
4
391 392 393 394 395 396 397 398 399 400 401 402 403 404 405 406 407 408 409 410 411 412 413 414 415 416 417 418 419 420 421 422 423 424 425 426 427 428 429 430 431 432 433 434 435 436 437 438 439 440 441 442 443 444 445 446 447 448 449 450 451 452 453 454 455
j o u r n a l o f s u r g i c a l r e s e a r c h - 2 0 1 6 ( - ) 1 e5
Table 5 e Do you feel head injuries cause disability more often than death? (n [ 398). Yes, % (n ¼ 389)
No, % (n ¼ 8)
Not sure, % (n ¼ 1)
Secondary or less
96.8
3.1
0
Postsecondary
98.3
1.2
0
<25
97.0
2.9
0
26-40
98.3
1.1
1.1
>41
92.6
7.3
0
P value
Education level 0.27
Age 0.64
2011 identified a helmet use rate of 58.7% among pillion riders, but when this was separated into helmet use rates by gender, only 0.6% of female pillions used helmets while on MTWs.12 Our study had similar findings, with 98.8% women reporting never using a helmet as a pillion rider. Even though these women do not personally wear helmets when riding on MTWs, most of them believed that there should be strict laws requiring female pillion riders to wear helmets (83.2%). Only 33% women were found to be aware of existence of mandatory helmet laws. More educated (postsecondary level [US ninth grade] or higher) women were more likely to be cognizant of these laws compared with women with lower levels of education (24.6%, P ¼ 0.005). In addition, most of the women interviewed (97%) believed that disability was more likely to result than death after a traumatic brain injury due to a road traffic incident. This leads us to believe that the average Pakistani woman is aware of the benefits of helmet use but is not aware of her requirement to wear one when riding an MTW. We feel that education at an early age about the existing mandatory helmet laws and reinforcing the benefits of helmet use could lead to improved awareness of the law’s existence and potentially improve compliance. Interestingly, 98.5% of women, regardless of age, level of education, or employment status, stated that they would wear a helmet if they were male riders instead. While imagining themselves as male pillion riders, 63.2%, of these women cited concerns for their personal safety would lead them to wear a helmet. We found this striking because none of the women wore helmets when riding pillion on MTWs, yet most of them are aware of the safety benefits of helmet use and would use helmets if male instead of female. This unquestionably highlights the importance spreading awareness about the importance of helmet use regardless of gender. In addition to
improved education in primary and secondary schools, it is also imperative that girls in particular be educated about the benefits of helmet use for women riders either in school or through community outreach programs. It is now well demonstrated that strict enforcement of helmet laws increases the rate of helmet use compliance. In Italy, a revised motorcycleemopedescooter helmet law increased helmet compliance from <20% to >96% between the years 1999 and 2001.13 Similarly, in Thailand, strong enforcement of legislation led to a fivefold increase in helmet use and decrease in head injuries among MTW users by 41% in a period of 2 y.14 Given that one in four Pakistani women did not wear helmets because they did not feel required to do so, a more proactive law enforcement policy would presumably encourage this large number of users to comply with helmet laws. The most common reason for not using a helmet cited by 29.2 % was physical appearance and discomfort. Many women felt they would actually draw negative attention if they used a helmet while on an MTW because of the rarity of female pillions wearing helmets. Many respondents also felt that the available safety helmets disrupt their physical appearance and hairstyles. Unfortunately, this was a more compelling argument against helmet use than any safety benefit incurred from using helmets. These results are similar to the study completed in New Delhi, India, from 2011, which also found discomfort and unattractive appearance as the main reasons women do not wear helmets as pillion riders.15 We believe if helmet manufactures would design breathable helmets fashioned specifically for hot climates and a smaller body habitus, this may address the female pillions’ concerns about comfort and appearance. When the women in our study were asked whether various forms of media influenced their behavior, television news was the most popular outlet cited (83.7%, n ¼ 334). According to two large meta-analyses conducted over the past decade by Elliot and Delhomme, mass media road safety campaigns can lead to an estimated 7.5% reduction of in road traffic incidents during the actual media campaign and a total reduction of 14.8% in road traffic incidents following campaign completion.16 We believe that helmet compliance among women all over Pakistan would increase significantly if the government and health agencies instituted a television mediaebased helmet use campaign. We also believe that the improved compliance gained from a helmet use campaign would be greater if it is done in conjunction with more complete enforcement of the existing helmet laws. Limitations of this study include the possibility of misinterpretations of responses given by the surveyed women along with the interpretive liberty taken to thematically categorize these responses.
Table 6 e Most influential form of media (n [ 400). Medium
n
%
Television news
334
83.7
Television shows
170
42.5
Television commercials
153
38.3
Movies
94
23.5
Celebrities
165
41.3
Newspaper
200
50.0
Conclusion With the increasing burden of injury related to road traffic incidents, it has become imperative to bring about a change in the public’s attitude toward safety. Television media helmet use campaigns and early education on the role of helmets in road traffic incidents in collaboration with government legislation and enforcement seem the most likely to lead to the
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much needed changes in behaviors of female pillion riders in Pakistan. Authors’ contributions: M.S. developed the study protocol, involved in data collection, analysis, drafting, and revision of the article. S.M.S. was involved in the study protocol, drafting, and revision of the article. U.R.K. was involved in the study protocol, data collection, and revision of the article. M.S. was involved in the study protocol and revision of the article.
Disclosures The authors reported no proprietary or commercial interest in any product mentioned or concept discussed in the article.
Supplementary data Supplementary data related to this article can be found at http://dx.doi.org/10.1016/j.jss.2016.11.063.
references
1. World Health Organization. WHO: Road Traffic Injuries. Fact sheet N 358. (Online). Available at: http://www.who.int/ mediacentre/factsheets/fs358/en/index.html. 2. Zhang J, et al. Motorcycle ownership and injury in China. Inj Control Saf Promotion. 2004;11:159e163. 3. Mohan D. Traffic safety and health in Indian cities. J Transport Infrastructure. 2002;9:79e94.
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4. Umar R. Helmet Initiatives in Malaysia. Paper Presented at: 2nd World Engineering Congress. Kuching: Sarawak, Malaysia; 2002. 5. Suriyawongpaisal P, Kanchanasut S. Road traffic injuries in Thailand: trends, selected underlying determinants and status of intervention. Inj Control Saf Promot. 2003;10:95e104. 6. Pakistan Bureau of Statistics. http://www.pbs.gov.pk/content/ population-census 7. World Health Organization. Global Status Report on Road Safety; 2015. http://www.who.int/violence_injury_prevention/road_ safety_status/2015/country_profiles/Pakistan.pdf. 8. Epidemiology of Karachi road traffic crash mortality in 2013. J Pakistan Med Assoc; 2015. http://www.jpma.org.pk/full_article_ text.php?article_id¼7353. 9. Liu BC, Ivers R, Norton R, Boufous S, Blows S, Lo SK. Helmets for preventing injury in motorcycle riders. Cochrane Database Syst Rev. 2008:CD004333. 10. Road Traffic Injury Research & Prevention center. Half Yearly Comparison; 2009. http://urckarachi.org/downloads%5CJan-toJun-2010-Report-14-Oct2010.pdf. 11. Xuequn Y, Ke L, Ivers R, Du W, Senserrick T. Prevalence rates of helmet use among motorcycle riders in a developed region in China. Accid Anal Prev. 2011;43:214e219. 12. Swaroop M. The problem of the pillion rider: India’s helmet law and New Delhi’s exemption. J Surg Res. 2014;188:64e68. 13. Servadei F, Begliomini C, Gardini E, Giustini M, Taggi F, Kraus J. Effect of Italy’s motorcycle helmet law on traumatic brain injuries. Inj Prev. 2003;9:257e260. 14. Ichikawa M. Effect of the helmet act for motorcyclists in Thailand. Accid Anal Prev. 2003;35:183e189. 15. Siddiqui S. Survey of helmet influences of female pillions in New Delhi. J Surg Res. 2013;184:404e410. 16. Delaney A, Monash University. Accident Research Centre. A Review of Mass Media Campaigns in Road Safety. Clayton, Vic: Monash University, Accident Research Centre; 2004.
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Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Q1
Q8
Q3
Perceptions regarding helmet use: a cross-sectional survey of female pillions in Karachi, Pakistan Maryam Saeed, MBBS,a Selma Marie Siddiqui, MD,b,* Uzma Rahim Khan, MBBS, MSc,a and Mamta Swaroop, MD, FACSc a
Aga Khan University, Karachi, Pakistan School of Medicine, Johns Hopkins University, Baltimore, Maryland c Feinberg School of Medicine, Northwestern University, Chicago, Illinois b
Q5
article info
abstract
Article history:
Background: In 2011, road traffic injuryeassociated fatalities among motorized two-wheeler
Received 22 July 2016
(MTW) pillion riders (backseat two-wheeler passengers) rose 30% in Karachi. Despite
Received in revised form
mandatory helmet laws, helmet use fell 20% the same year. This study aims to identify
8 November 2016
opinions of female pillions on helmet usage and whether various forms of media influence
Accepted 30 November 2016
their self-perception.
Available online xxx
Methods: Trained surveyors, using a survey tool used in similar studies in South Asia, conducted random, man-on-the-street interviews of 400 women in four areas of Karachi.
Keywords:
Data pertaining to demographics, opinions on helmet laws, media influences, and
Pillion riders
helmet usage were collected. Data were analyzed in SAS 9.3 using chi-squared or Fisher’s
Motorized two wheeler
exact tests.
Karachi
Results: Of the 400 women, 98.8% (n ¼ 394) reported never wearing a helmet while riding on
Pakistan
a MTW as a pillion rider. Women with a postsecondary or higher (US ninth grade)
Helmet use
education level were more likely to be aware of helmet laws (38.6%) than women with lower education levels (24.6%, P ¼ 0.005). Most women (82.4%, n ¼ 329) supported mandatory laws and 97% (n ¼ 289) recognized that disability was the more likely to result than death in event of a traumatic brain injury. Nearly all (98.5%, n ¼ 394) stated that they would use a helmet if they were men, regardless of age, education level, or employment status. Television news was the most influential media form (83.7%, n ¼ 334), with most women finding it effective because of its informative nature (91.3%, n ¼ 303). Conclusions: Most Pakistani women do not personally use helmets when riding MTWs, yet most believe helmet use should be legally required for MTW riders and drivers. These data show that media outlets such as television can be used as a platform to educate the public about helmet usage, which may lead to improved helmet compliance among female MTW pillions in Pakistan. Furthermore, investigations into improved helmet comfort and appearance by collaborating with helmet manufacturers may have a positive impact on helmet use in Pakistan. ª 2016 Elsevier Inc. All rights reserved.
This work was presented at the AAS February 2014 Academic Surgical Congress. * Corresponding author. School of Medicine, Johns Hopkins University, Surgery 600 N. Wolfe Street, Osler 603, Baltimore, MD 21287. Tel.: þ1 9199619568 (Mobile); fax: þ1 9199619568. Q4 E-mail address: [email protected] (S.M. Siddiqui). 0022-4804/$ e see front matter ª 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2016.11.063
5.4.0 DTD YJSRE14088_proof 28 December 2016 4:46 pm ce
66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130
2
131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195
j o u r n a l o f s u r g i c a l r e s e a r c h - 2 0 1 6 ( - ) 1 e5
Introduction According to the World Health Organization’s (WHO) Global Road Safety Report 2015, approximately 1.25 million people die annually as a result of road traffic crashes. Half of these crashes involve “vulnerable road users” including pedestrians, cyclist, and motorcyclists. Motorized two wheelers (MTWs) are the most prevalent mode of transportation in lowand middle-income countries. However, because of minimal safety features, they are statistically more likely to be involved in serious accidents.1 In China, motorcycle ownership between year 1987 and 2001 grew rapidly from 23% to 63%, with a corresponding increase in the proportion of traffic fatalities sustained by motorcyclists rising from 7.5% to 19% over the same period.2 This trend is seen across South and South East Asia, with the proportion of MTW-associated road accident fatalities ranging from 27% in India,3 60% in Malaysia,4 and between 60% and 90% in Thailand.5 Pakistan, a developing country of 182 million people,6 has more than 9 million registered vehicles, 61.2% of which are two- or three-wheeler vehicles. According to the WHO’s report, 7636 road traffic injury (RTI)-associated fatalities were reported from Pakistan in 2013.7 However, underreporting skews, these numbers such that the WHO estimated an actual 25,781 RTI-associated fatalities, most of which involved twoand three-wheeler vehicles. The Road Traffic Injury Research and Prevention Center is an organization based in Karachi, Pakistan, that is actively involved in surveillance of RTIs in Karachi. According to data they collected in 2013, there were 1130 fatalities that year with 51% of those being MTW drivers and pillion (backseat MTW passenger) riders.8 Helmets are considered the primary mode of protection against head injuries with regards to MTW, reducing the risk of death by 42% and the risk of head injury by 69%.9 These data strongly support the use of helmets, and Pakistan has passed legislation mandating helmet use for all MTW riders. However, empirically compliance with these laws remains low, and helmets are rarely used by female pillion riders. Studies in culturally similar neighboring India have shown a low helmet compliance rate among female pillion riders despite the existence of a mandatory helmet law. Our study aims to determine the attitudes of female pillion riders regarding helmet usage and determine whether various media outlets influence these perceptions. We hypothesize that most women will not be aware of Pakistan’s existing helmet laws. We also hypothesize that most women will report that television media outlets are influential on their helmet use habits.
adjusted to improve internal validity. These 15 surveys were not included in the data set for analysis. Five trained survey administrators completed 400 surveys at four popular shopping centers in Karachi, Pakistan: Gulf Shopping Center, Tariq road, Saddar Bazaar, and Meena Bazaar. These were chosen because of their heavy volume of female pedestrian traffic. Females aged 18 y were included for survey administration, and females aged <18 y were excluded. A verbal consent was obtained before the interview. The survey was administered in a face-to-face interview in Urdu, whereby trained survey administrators read the questions for the respondents and recorded the responses on paper. No identifying information from respondents was queried or recorded. The collected responses were entered into Microsoft Excel (Microsoft Corporation, Redmond, WA). Similar themes among the open-ended answers were identified, and the responses were grouped into these themes categories for analysis. The data were analyzed in SAS version 9.3 (Cary, NC), and Microsoft Excel Comparisons of respondents’ use of helmets and beliefs regarding helmet and head injuries were made using chi-squared and Fisher’s exact tests. The Ethics Committee of Aga Khan University Hospital approved this study.
Results All 400 surveys were completed in Urdu. Several forms were partially completed; completed responses from these surveys were included in our analyses.
Table 1 e Survey population demographics (n [ 400). n
%
25
138
34.5
26-40
180
45
41
82
20.5
Working
127
31.7
Not working
273
68.2
Married
269
67.2
Unmarried
131
32.7
20
5.0
Age (y)
Employment
Marital status
Education* None High school
Methods A survey was developed in English comprising of 25 multiplechoice questions with each question followed by an openended query (Appendix 1). The survey included questions regarding demographics, opinion on helmet laws, media influences, and helmet use. A trained bilingual survey administrator translated the survey from English to Urdu. The sample survey was tested on 15 random individuals, and the survey was
231
57.9
University
99
24.8
Advanced degree
49
12.3
365
91.3
Hindu
13
3.3
Christian
22
5.5
Religion Muslim
*
Because of respondent omission, education level is reported for an n of 399 respondents rather than 400.
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196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260
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261 262 263 264 265 266 267 268 269 270 271 272 273 274 275 276 277 278 279 280 281 282 283 284 285 286 287 288 289 290 291 292 293 294 295 296 297 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322 323 324 325
Self-reported demographics of the women surveyed are listed (Table 1). Of the 400 women surveyed, 98.8% (n ¼ 394) had never worn a helmet while riding on a MTW as a pillion. When asked about their reasons for not using a helmet, 29.2% (n ¼ 113) cited appearance as the primary reason. Lack of legal mandate necessitating helmet use was the next most common reason, cited by 26.2% (n ¼ 102), followed by the belief that helmets are ineffective in case of a road traffic crash (Table 2). When asked if they knew about laws related to helmet use, 33% (n ¼ 132) acknowledged being aware of laws mandating helmet use for both the driver and pillion rider(s), whereas 64.5% (n ¼ 248) were unaware of the existence of such laws. Women with a postsecondary or higher (US ninth grade) education were more likely to be aware of helmet laws (38.6%) than women with less education (24.6%, P ¼ 0.005; Table 3). Most women, 83.2% (n ¼ 329), affirmed that there should be strict laws requiring female pillion riders to wear helmets (Table 4). Regardless of age, level of education, or employment status, 98.5% of women (n ¼ 394) reported that they would wear a helmet if they were male riders. Safety was cited as the main reason for using a helmet by 63.2% (n ¼ 249). Nearly all the women surveyed (97%, n ¼ 289) felt that a disability would occur more frequently than death in the event of a traumatic brain injury (Table 5). Respondents were asked whether various forms of media influence their behavior and attitudes with 83.7% (n ¼ 334) of women citing television news as influential on their behavior patterns (Table 6). Most women, 91.3% (n ¼ 303), found television news effective because of its informative nature. When asked whether religious affiliation influenced their attitudes and behaviors, most women (96.8%, n ¼ 387) believed that religious groups had a considerable influence on their behavior.
Discussion Karachi, the financial capital of Pakistan and its largest city, reported 9000 RTIs among MTW drivers and pillion (backseat MTW passenger) riders in the year 2009. According to the Road Traffic Injury and Research Prevention Center, >95% of drivers
Table 2 e Reasons for helmet disuse while riding pillion (n [ 397). Reasons reported
n
%
Appearance
116
29.2
No legal mandate
104
26.2
33
8.3
Never thought about it No need
32
8.1
Nobody uses it
30
7.6
Discomfort
22
5.5
Other*
60
15.1
*
These responses included things such as helmets are ineffective, helmets cannot be used with scarves and head coverings, helmets interfere with children on lap, and helmets are not available in women’s sizes.
Q7 326
Table 3 e Is there a helmet law in place? (n [ 400). Yes, % (n ¼ 132)
No, % (n ¼ 259)
Do not know, % (n ¼ 9)
P value
Secondary or less
24.6
71.5
3.7
0.005
Postsecondary
38.5
59.4
1.2
Yes
28.3
68.5
3.1
No
35.1
63
1.8
Yes
34.5
63.1
2.2
No
29.7
67.9
2.2
Muslim
32.8
64.9
2.2
Hindu
30.7
61.5
7.6
Christian
36.3
63.6
0
<25
29.7
67.3
2.9
26-40
35
63.3
1.6
>41
34.1
63.4
2.4
Education level
Employed 0.31
Married 0.62
Religion 0.59
Age (y) 0.80
and pillion riders involved in these incidents were not wearing safety helmets. Despite the presence of mandatory laws, helmets use remains low, especially among pillion riders.10 A cross-sectional observational study in China revealed that the rate of correct helmet use was a mere 20.9% across all pillions.11 A similar study conducted in New Delhi, India, in
Table 4 e Should women pillion riders be legally mandated to use helmets? (n [ 400). Yes, % (n ¼ 329)
No, % (n ¼ 67)
Not sure, % (n ¼ 3)
P value
Secondary or less
79.1
20.2
0.63
0.24
Postsecondary
85
14.1
0.83
Education level
Employed Yes
85
14.1
0.7
No
81.2
18
0.7
Yes
80.2
19
0.74
No
87
12.2
0.76
Muslim
81.8
17.3
0.82
Hindu
69.2
30.7
0
0
0
0.62
Married 0.18
Religion
Christian
100
0.07
Age (y) <25
82.4
17.5
0
26-40
80.5
17.7
1.6
>41
86.5
13.4
0
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Q2
0.50
327 328 329 330 331 332 333 334 335 336 337 338 339 340 341 342 343 344 345 346 347 348 349 350 351 352 353 354 355 356 357 358 359 360 361 362 363 364 365 366 367 368 369 370 371 372 373 374 375 376 377 378 379 380 381 382 383 384 385 386 387 388 389 390
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391 392 393 394 395 396 397 398 399 400 401 402 403 404 405 406 407 408 409 410 411 412 413 414 415 416 417 418 419 420 421 422 423 424 425 426 427 428 429 430 431 432 433 434 435 436 437 438 439 440 441 442 443 444 445 446 447 448 449 450 451 452 453 454 455
j o u r n a l o f s u r g i c a l r e s e a r c h - 2 0 1 6 ( - ) 1 e5
Table 5 e Do you feel head injuries cause disability more often than death? (n [ 398). Yes, % (n ¼ 389)
No, % (n ¼ 8)
Not sure, % (n ¼ 1)
Secondary or less
96.8
3.1
0
Postsecondary
98.3
1.2
0
<25
97.0
2.9
0
26-40
98.3
1.1
1.1
>41
92.6
7.3
0
P value
Education level 0.27
Age 0.64
2011 identified a helmet use rate of 58.7% among pillion riders, but when this was separated into helmet use rates by gender, only 0.6% of female pillions used helmets while on MTWs.12 Our study had similar findings, with 98.8% women reporting never using a helmet as a pillion rider. Even though these women do not personally wear helmets when riding on MTWs, most of them believed that there should be strict laws requiring female pillion riders to wear helmets (83.2%). Only 33% women were found to be aware of existence of mandatory helmet laws. More educated (postsecondary level [US ninth grade] or higher) women were more likely to be cognizant of these laws compared with women with lower levels of education (24.6%, P ¼ 0.005). In addition, most of the women interviewed (97%) believed that disability was more likely to result than death after a traumatic brain injury due to a road traffic incident. This leads us to believe that the average Pakistani woman is aware of the benefits of helmet use but is not aware of her requirement to wear one when riding an MTW. We feel that education at an early age about the existing mandatory helmet laws and reinforcing the benefits of helmet use could lead to improved awareness of the law’s existence and potentially improve compliance. Interestingly, 98.5% of women, regardless of age, level of education, or employment status, stated that they would wear a helmet if they were male riders instead. While imagining themselves as male pillion riders, 63.2%, of these women cited concerns for their personal safety would lead them to wear a helmet. We found this striking because none of the women wore helmets when riding pillion on MTWs, yet most of them are aware of the safety benefits of helmet use and would use helmets if male instead of female. This unquestionably highlights the importance spreading awareness about the importance of helmet use regardless of gender. In addition to
improved education in primary and secondary schools, it is also imperative that girls in particular be educated about the benefits of helmet use for women riders either in school or through community outreach programs. It is now well demonstrated that strict enforcement of helmet laws increases the rate of helmet use compliance. In Italy, a revised motorcycleemopedescooter helmet law increased helmet compliance from <20% to >96% between the years 1999 and 2001.13 Similarly, in Thailand, strong enforcement of legislation led to a fivefold increase in helmet use and decrease in head injuries among MTW users by 41% in a period of 2 y.14 Given that one in four Pakistani women did not wear helmets because they did not feel required to do so, a more proactive law enforcement policy would presumably encourage this large number of users to comply with helmet laws. The most common reason for not using a helmet cited by 29.2 % was physical appearance and discomfort. Many women felt they would actually draw negative attention if they used a helmet while on an MTW because of the rarity of female pillions wearing helmets. Many respondents also felt that the available safety helmets disrupt their physical appearance and hairstyles. Unfortunately, this was a more compelling argument against helmet use than any safety benefit incurred from using helmets. These results are similar to the study completed in New Delhi, India, from 2011, which also found discomfort and unattractive appearance as the main reasons women do not wear helmets as pillion riders.15 We believe if helmet manufactures would design breathable helmets fashioned specifically for hot climates and a smaller body habitus, this may address the female pillions’ concerns about comfort and appearance. When the women in our study were asked whether various forms of media influenced their behavior, television news was the most popular outlet cited (83.7%, n ¼ 334). According to two large meta-analyses conducted over the past decade by Elliot and Delhomme, mass media road safety campaigns can lead to an estimated 7.5% reduction of in road traffic incidents during the actual media campaign and a total reduction of 14.8% in road traffic incidents following campaign completion.16 We believe that helmet compliance among women all over Pakistan would increase significantly if the government and health agencies instituted a television mediaebased helmet use campaign. We also believe that the improved compliance gained from a helmet use campaign would be greater if it is done in conjunction with more complete enforcement of the existing helmet laws. Limitations of this study include the possibility of misinterpretations of responses given by the surveyed women along with the interpretive liberty taken to thematically categorize these responses.
Table 6 e Most influential form of media (n [ 400). Medium
n
%
Television news
334
83.7
Television shows
170
42.5
Television commercials
153
38.3
Movies
94
23.5
Celebrities
165
41.3
Newspaper
200
50.0
Conclusion With the increasing burden of injury related to road traffic incidents, it has become imperative to bring about a change in the public’s attitude toward safety. Television media helmet use campaigns and early education on the role of helmets in road traffic incidents in collaboration with government legislation and enforcement seem the most likely to lead to the
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much needed changes in behaviors of female pillion riders in Pakistan. Authors’ contributions: M.S. developed the study protocol, involved in data collection, analysis, drafting, and revision of the article. S.M.S. was involved in the study protocol, drafting, and revision of the article. U.R.K. was involved in the study protocol, data collection, and revision of the article. M.S. was involved in the study protocol and revision of the article.
Disclosures The authors reported no proprietary or commercial interest in any product mentioned or concept discussed in the article.
Supplementary data Supplementary data related to this article can be found at http://dx.doi.org/10.1016/j.jss.2016.11.063.
references
1. World Health Organization. WHO: Road Traffic Injuries. Fact sheet N 358. (Online). Available at: http://www.who.int/ mediacentre/factsheets/fs358/en/index.html. 2. Zhang J, et al. Motorcycle ownership and injury in China. Inj Control Saf Promotion. 2004;11:159e163. 3. Mohan D. Traffic safety and health in Indian cities. J Transport Infrastructure. 2002;9:79e94.
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4. Umar R. Helmet Initiatives in Malaysia. Paper Presented at: 2nd World Engineering Congress. Kuching: Sarawak, Malaysia; 2002. 5. Suriyawongpaisal P, Kanchanasut S. Road traffic injuries in Thailand: trends, selected underlying determinants and status of intervention. Inj Control Saf Promot. 2003;10:95e104. 6. Pakistan Bureau of Statistics. http://www.pbs.gov.pk/content/ population-census 7. World Health Organization. Global Status Report on Road Safety; 2015. http://www.who.int/violence_injury_prevention/road_ safety_status/2015/country_profiles/Pakistan.pdf. 8. Epidemiology of Karachi road traffic crash mortality in 2013. J Pakistan Med Assoc; 2015. http://www.jpma.org.pk/full_article_ text.php?article_id¼7353. 9. Liu BC, Ivers R, Norton R, Boufous S, Blows S, Lo SK. Helmets for preventing injury in motorcycle riders. Cochrane Database Syst Rev. 2008:CD004333. 10. Road Traffic Injury Research & Prevention center. Half Yearly Comparison; 2009. http://urckarachi.org/downloads%5CJan-toJun-2010-Report-14-Oct2010.pdf. 11. Xuequn Y, Ke L, Ivers R, Du W, Senserrick T. Prevalence rates of helmet use among motorcycle riders in a developed region in China. Accid Anal Prev. 2011;43:214e219. 12. Swaroop M. The problem of the pillion rider: India’s helmet law and New Delhi’s exemption. J Surg Res. 2014;188:64e68. 13. Servadei F, Begliomini C, Gardini E, Giustini M, Taggi F, Kraus J. Effect of Italy’s motorcycle helmet law on traumatic brain injuries. Inj Prev. 2003;9:257e260. 14. Ichikawa M. Effect of the helmet act for motorcyclists in Thailand. Accid Anal Prev. 2003;35:183e189. 15. Siddiqui S. Survey of helmet influences of female pillions in New Delhi. J Surg Res. 2013;184:404e410. 16. Delaney A, Monash University. Accident Research Centre. A Review of Mass Media Campaigns in Road Safety. Clayton, Vic: Monash University, Accident Research Centre; 2004.
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