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Prevalence rates of helmet use among motorcycle riders in a developed region in China
Accident Analysis and Prevention 43 (2011) 214–219
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Accident Analysis and Prevention journal homepage: www.elsevier.com/locate/aap
Prevalence rates of helmet use among motorcycle riders in a developed region in China Yu Xuequn a,∗ , Liang Ke a , Rebecca Ivers b , Wei Du a,b , Teresa Senserrick b a b
The George Institute for International Health, China, Beijing, China Injury Division, The George Institute for International Health, The University of Sydney, Australia
a r t i c l e
i n f o
Article history: Received 11 March 2010 Received in revised form 11 August 2010 Accepted 13 August 2010 Keywords: Motorcycle Helmet Epidemiology Road safety
a b s t r a c t This study aimed to determine the prevalence rates of helmet use, and of correct helmet use (chinstrap firmly fastened) among motorcycle riders and their passengers in Zhongshan, Guangdong Province, China. A cross-sectional survey involving direct observation of motorcycle riders was conducted at 20 randomly selected intersections. A total of 13,410 motorcycles were observed during a 10-day period in February 2009. The overall prevalence of helmet use was 72.6% (95% CI: 71.8–73.3%) among drivers and 34.1% (95% CI: 32.7–35.5%) among pillion passengers. The prevalence of correct use was 43.2% (95% CI: 42.4–44.0%) and 20.9% (95% CI: 19.8–22.1%) for drivers and passengers respectively. The helmet wearing rate on city streets was almost 95%, however city riders were more likely than rural riders to wear non-motorcycle helmets while riding. In multivariate analyses, factors associated with increased helmet use included riding on city streets, male gender, being a driver, carrying less passengers and riding a registered motorcycle. The results indicated enforcement and education activities need to be strengthened with respect to both helmet use and helmet quality, especially in rural areas, in order to improve wearing rates. © 2010 Elsevier Ltd. All rights reserved.
1. Introduction Road traffic injury in China is a significant public health issue. The Ministry of Public Security in China reports that from 2003 to 2007 the number of road fatalities in China was nearly 100,000 per year and the number of seriously injured nearly 500,000 (Traffic Administration Bureau of China Public Security Ministry, 2008). Road collisions are reported to be the main cause of death in China for those aged 45 years and below (World Health Organization, 2008). Due to increasing motor vehicle ownership associated with rapid economic development, without effective interventions the number of road traffic injuries are expected to be even more significant in the next decade (Ameratunga et al., 2006). Since the 1980s, due to the city governors’ concern about motorcycle related issues including road traffic injuries, pollution and traffic chaos, motorcycles have been restricted from travelling on public roads in large cities such as Beijing, Shanghai and more recently Guangzhou. However motorcycles, as a convenient and affordable means of transportation, are used extensively in small to medium cities and rural areas of southern China. The total number of motorcycles owned in China increased from 2.5 million (about
∗ Corresponding author at: Research & Development, The George Institute, China, Room 1302, Tower B, Horizon Plaza, No. 6 Zhichun Road, Haidian District, Beijing 100088, PR China. Tel.: +86 10 82800577x308; fax: +86 10 82800177. E-mail address: [email protected] (Y. Xuequn). 0001-4575/$ – see front matter © 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.aap.2010.08.012
23% of total motorized vehicles) in 1987 to 50 million (about 70%) in 2002, and to 70 million (about 54%) in 2005 (National Bureau of Statistics, 2006). In accordance with this increase, the proportion of traffic fatalities sustained by motorcyclists also increased significantly from 7.5% in 1987 to 18.9% in 2001 (Zhang et al., 2004), and to 22.2% in 2007 (Traffic Administration Bureau of China Public Security Ministry, 2008). The proportion of traffic fatalities is even higher in some areas where motorcycle use is more common, for example 43.0% of total traffic fatalities in Guangzhou prior to the restrictions (Li, 2006 September 20). Motorcycle helmets decrease head injuries in a crash by about 70% and death by about 40% (Liu et al., 2009), and reduce the length of hospital stay and the medical costs of injured riders (Chesham et al., 1993). The Regulation of Road Traffic Administration which came into effect in March 1988 made helmet usage mandatory for all two-wheeled motorcycle riders in China (The State Council of the People’s Republic of China, 1988). Under the Road Traffic Safety Law of the People’s Republic of China which was enacted from May 2004, the penalty for not wearing a safety helmet was raised from 5 RMB (less than 1 USD) to 20–200 RMB (about 3–30 USD). However, despite the existing legislation and penalties in China, the reported rates of helmet use have remained low, with estimates ranging from 30% to 60% (Junhua et al., 2004; Liping et al., 2008). Even with national legislation, helmet usage rates and pattern may vary widely from one region to the next depending on educational level, penalty charge and enforcement activities (World Health Organization, 2006). Few previous studies have been
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conducted in the developed regions of China, currently experiencing rapid motorization. In order to examine the prevalence rates and pattern of helmet use in these regions, we conducted roadside observations in Zhongshan city, a typical economically developed region in Southern China. 2. Methods 2.1. Location This study was conducted in February 2009 in a southern prefecture-level city of China, Zhongshan, which is situated in the Pearl River Delta, with an area of 1679 km2 and a population of 2.49 million. It is composed of 5 districts (and Xiao Lan town) that can be classified as urban locations and 17 towns classified as rural locations. In 2008 the city ranked 15th in a list of more than 200 cities in China by per capita income. In November 1999, to restrict the increasing number of motorcycles, the Zhongshan government ceased registration of new motorcycles plates. The number of registered motorcycles has thus remained constant at approximately 350,000 (Zhongshan Statistic Bureau, 2009), with approximately 1 in 7 citizens owning a motorcycle. However this number does not include the unregistered motorcycles. 2.2. Roadside observation In February 2010, a cross-sectional on-site observational survey was implemented based on a random sample of the road hierarchy in the city. At each of 20 randomly selected observation sites, data was collected for 3 separate hours at daytime (7 am–7 pm). 2.2.1. Site selection To select the roadside sites, a grid with sections measuring 2 cm by 2 cm was placed over a standard map of Zhongshan and drawn to a scale of 1 cm = 1.85 km. Each grid box contained an area of approximately 3.42 km2 . The grid dimensions were 26 lines horizontally and 18 lines vertically. Each valid grid box containing at least one intersection in an included part of Zhongshan was numbered. The selection of sites was based on proportion of the population in urban and rural areas of the city to avoid the sites over representing the non-urban areas. In this way 8 sites from urban areas (including 4 districts and Xiao Lang town) and 12 sites from rural areas were selected. Random numbers were generated to select grid boxes from which specific intersections were selected. For each site an alternate site was also selected randomly from the box as a backup. Researchers visited and evaluated each site prior to the study to determine whether the site was suitable for the observation. The availability of traffic lights or stop signs and safety of observers were the main considerations. If the original site did not meet the requirements, the researchers would visit and evaluate the alternate site. If neither the original site nor the alternate site met the requirements, the researchers then identified another suitable site that was closest to the original site (the third site). Among the 20 observational sites, 9 alternate sites and 1 third site were used. The day of week and time of day for site observation were randomly assigned to sites in such a way that all days of the week and all daylight hours (7 am–7 pm) had equal probability of selection. 2.2.2. Observation techniques All the observations were undertaken whilst the motorcycle was stationary. The observers conducted their roadside observations solely at intersections controlled by a stop sign or stoplight, recording information of gender, helmet use, whether the chinstrap was fastened and helmet type of motorcycle riders. Registration status of the motorcycle was collected, and this was determined by whether a registration plate was displayed on the front and/or
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rear of the vehicle. Mopeds, electric scooters and motor scooters less than 50 cc were excluded from observations because it is not mandatory for the riders of these vehicles to use a helmet. Helmet designs were classified as full face, open face, half face and those not designed for motorcycle use (non-motorcycle helmet), such as ‘sun helmet’, construction helmet, combat helmet and others (see Fig. 1 for examples). Helmet use was classified as ‘correct use’ (chinstrap firmly fastened), ‘incorrect use’ (chinstrap not firmly fastened or not fastened) and ‘no helmet use’. Road types were classified as ‘city street’, ‘county road’, ‘provincial road’ and ‘national road’ according to designations from the city authorities. The “city street” is unique to the urban settings and the other 3 types of road are characteristic of rural settings. 2.2.3. Observers training and audits Observers were recruited from local colleges. Prior to data collection, the 10 field observers attended 1 day of intensive training and were trained in techniques to observe the correct use of helmets at the roadside observational sites. The observers worked in teams of two, observing the same motorcycle and recording data independently on separate data collection forms. Teams were rotated throughout the training to ensure that each observer was paired with every other observer. The inter-observer reliability for each pair of observers was at least 85% for both observed drivers and passengers. On-site audits were made by the researchers during data collection to ensure adherence to study protocols. 2.3. Ethical issues Ethical approval for this study was obtained from the Human Ethics Committee of Peking University Health Science Center. No identifying information of riders was collected in the roadside observation. 2.4. Statistical analysis SAS version 9.1 (SAS Institute, Cary, NC) was used to conduct all data analyses, which were stratified by mode of travel, i.e., motorcycle riders or passengers. Frequencies, proportions and their associated 95% confidence intervals (CI) for helmet use and helmet correct use by variables including sex, day of week, time of day, road type, number of passengers or additional passengers, weather, and registration status were calculated. The Chi-square test was used to examine the proportional difference between road types, where appropriate. Multivariate logistic regression was further used to estimate the adjusted odds ratio (OR) with 95% confidence limits (95% CI) of helmet use for variables of interest including sex, day of week, time of day, road type, number of passengers/additional passengers, weather, and licence status. p-Values less than 0.05 were defined as statistically significant. 3. Results A total of 13,410 drivers and 4498 passengers were observed at the 20 randomly selected sites. Where gender was able to be estimated, as shown in Tables 1 and 2, of the observed drivers 10,629 were men and 2776 were women (male:female ratio 3.83), while of the observed passengers, 1847 were men and 2394 women (male:female ratio 0.77). Of the observed motorcycles, 9321 (69.5%) had no pillion passenger, 3694 (27.6%) carried one pillion passenger, and 395 (2.9%) carried two or more pillion passengers. Of all observed pillion passenger, 225 (5.0%) were recorded as children younger than 12 years of age. Most (99.3%) observed motorcycles were recorded as registered. The prevalence of helmet use for drivers was 72.6% (95% CI: 71.8–73.3%) compared with 34.1% (95% CI: 32.7–35.5%) for pillion
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Fig. 1. Examples of non-motorcycle helmets. Table 1 Characteristics of motorcycle drivers in Zhongshan, China, 2009.
Drivers Sex Male Female Weekday Workday Weekend Time 7:009:0017:00–19:00 Road type City street County road Provincial road National road No. of passengers No passenger One passenger ≥Two passengers Weather Sunny Cloudy Rain Registered Yes No
N (%)
Helmet wearing rate (%)
95% CI
Correctly wearing rate (%)
95% CI
13,410
72.6
71.8–73.3
43.2
42.4–44.0
10,629 (79.3) 2776 (20.7)
72.1 74.5
71.2–72.9 72.8–76.1
41.3 50.4
40.4–42.2 48.5–52.2
9967 (74.3) 3443 (25.7)
72.8 72.0
71.9–73.7 70.4–73.4
43.4 42.6
42.4–44.4 41.0–44.3
695 (5.2) 12,103 (90.3) 612 (4.6)
65.8 72.1 89.1
62.2–69.3 71.3–72.9 86.6–91.5
37.4 43.0 54.3
33.8–41.0 42.1–43.8 50.3–58.2
2627 (19.6) 4099 (30.6) 2711 (20.2) 3973 (29.6)
96.8 65.0 74.6 63.0
96.1–97.4 63.5–66.4 73.0–76.2 61.5–64.5
60.3 36.6 45.0 37.4
58.4–62.1 35.1–38.1 43.1–46.9 35.9–38.9
9321 (69.5) 3694 (27.6) 395 (2.9)
74.7 68.1 63.3
73.8–75.6 66.6–69.6 58.5–68.0
43.9 41.6 40.0
42.9–45.0 40.0–43.2 35.2–44.8
6102 (45.8) 6923 (52.0) 290 (2.2)
73.4 71.7 67.2
72.3–74.5 70.6–72.7 61.8–72.6
45.5 41.2 40.3
44.2–46.7 40.0–42.4 34.7–46.0
13,257 (99.3) 100 (0.7)
72.9 22.0
72.2–73.7 13.9–30.1
43.4 11.0
42.6–44.3 0.5–17.1
95% CI
Correctly wearing rate (%)
Table 2 Characteristics of motorcycle passengers in Zhongshan, China, 2009. N (%) Passengers Sex Male Female Weekday Workday Weekend Time 7:009:0017:00–19:00 Road type City street County road Provincial road National road No. of passengers One passenger ≥Two passengers Weather Sunny Cloudy Rain Registered Yes No
Helmet wearing rate (%)
95% CI
4498 (100)
34.1
32.7–35.5
20.9
19.8–22.1
1847 (43.5) 2394 (56.4)
30.1 40.6
28.0–32.2 38.6–42.6
16.4 26.7
14.7–18.0 24.9–28.4
3074 (68.3) 1424 (31.7)
35.7 30.6
34.0–37.4 28.2–33.0
22.4 17.8
20.9–23.9 15.9–19.8
190 (4.2) 4157 (92.4) 151 (3.4)
28.4 33.4 60.3
22.0–34.8 32.0–34.8 52.5–68.1
18.4 20.4 39.7
12.9–23.9 19.2–21.6 31.9–47.5
609 (13.5) 1464 (32.6) 1013 (22.5) 1412 (31.4)
84.1 23.6 38.0 20.6
81.2–87.0 21.4–25.7 35.0–41.0 18.5–22.7
54.7 13.9 22.3 12.7
50.7–58.6 12.2–15.7 19.8–24.9 10.9–14.4
3694 (82.1) 804 (17.9)
40.2 6.0
38.6–41.8 4.3–7.6
24.6 4.1
23.2–26.0 2.7–5.5
2060 (46.2) 2292 (51.4) 109 (2.4)
36.9 31.5 18.4
34.8–39.0 29.6–33.5 11.1–25.6
23.3 19.1 10.1
21.5–25.1 17.5–20.7 0.4–15.8
4435 (99.2) 37 (0.8)
34.2 0.8
32.8–35.6 0.0–16.9
21.1 0.0
19.9–22.3 0.0–0.0
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Table 3 Results of logistic regression analysis of predictors associated with non-helmet use among motorcycle drivers and passengers in Zhongshan, China 2009.
Driver
Passenger
Road type City street County road Provincial road National road No. of passengers 0 1 ≥2 Sex Male Female Time 7:009:0017:00–19:00 Registration Yes No Weather Sunny Cloudy Rainy Weekday Monday–Friday Saturday–Sunday Road type City street County road Provincial road National road Additional passengers 0 ≥1 Sex Male Female Time 7:009:0017:00–19:00 Registration Yes No Weather Sunny Cloudy Rainy Weekday Monday–Friday Saturday–Sunday
OR
Lower CI
Upper CI
p-Value
Reference 15.51 9.68 16.93
12.31 7.63 13.44
19.54 12.28 21.32
<.0001 <.0001 <.0001
Reference 1.27 1.41
1.16 1.13
1.38 1.75
<.0001 0.002
Reference 1.07
0.96
1.18
0.228
Reference 1.10 0.93
0.93 0.66
1.30 1.29
0.265 0.646
Reference 12.26
7.21
20.84
Reference 1.08 0.88
0.98 0.68
1.18 1.15
0.122 0.353
Reference 1.03
0.93
1.15
0.530
Reference 26.60 13.21 30.80
19.32 9.55 22.28
36.63 18.29 42.56
<.001 <.001 <.001
Reference 12.79
8.98
18.21
<.001
Reference 0.60
0.51
0.70
<.001
Reference 1.55 0.87
0.78 0.49
1.10 1.53
0.607 0.620
Reference 8.57
2.22
33.08
0.002
Reference 1.30 1.46
1.09 0.85
1.552 2.50
0.004 0.167
Reference 0.95
0.78
1.15
0.567
passengers. Rates of correct helmet use were lower, being 43.2% (95% CI: 42.4–44.0%) for drivers and 20.9% (95% CI: 19.8–22.1%) for passengers respectively. The prevalence of helmet use on city streets was 96.8% and 84.1% for drivers and pillion passengers respectively, while the rates were much lower for other road types. Multivariate analyses (Table 3) showed that the strongest predictor for helmet use among drivers was the type of road they were traveling on. Compared to drivers on city streets, the adjusted OR for unhelmeted drivers was 15.51 (95% CI: 12.31–19.54), 9.68 (95% CI: 7.63–12.28) and 16.93 (95% CI: 13.44–21.32) for national, provincial and county roads respectively. Helmet use among drivers was also significantly associated with number of passengers and registration status. Drivers riding a registered motorcycle and with fewer passengers were more likely to wear a helmet than those with an unregistered motorcycle and with more passengers. There was also a statistically significant impact of road type, number of additional passengers and registration status on helmet use among passen-
<.0001
gers. In addition, helmet use among passengers was also associated with gender and weather, i.e., helmet use among male passengers was significantly lower than that of female passengers (adjusted OR = 0.60, 95% CI: 0.51–0.70), and passengers riding on a cloudy day were less likely to be wearing a helmet than those on sunny days (adjusted OR = 1.30, 95% CI: 1.09–1.55). No statistically significant association was found for helmet use with the time or weekday of observation. Among the 13,410 drivers and 4233 passengers observed, 1676 (12.5%) and 643 (15.2%) were wearing non-motorcycle helmets. Only 4965 (37.0%) drivers and 548 (12.9%) passengers were wearing helmets designed for motorcyclists that were properly secured (data not shown). There were statistically significant relationships between types of helmet use and road types traveled (for drivers, 2 = 603.9, p < 0.001; for passengers, 2 = 758.7, p < 0.001). Fig. 2 shows the highest proportion of people wearing non-standard helmets was those traveling on city streets (28.1% for drivers and 60.4% for passengers respectively).
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Fig. 2. Characteristics of helmet type among motorcycle drivers and passengers by road type in Zhongshan, China, 2009.
4. Discussion This study found that the overall prevalence of helmet use in Zhongshan was 72.6% among drivers and 34.1% among pillion passengers. The crude usage rate of 62.0% for all riders (drivers and passengers) was higher than the results of two previous surveys in less developed regions of China (Junhua et al., 2004; Liping et al., 2008). Zhang et al. found that helmet wearing rates were 56.2% for the riders in Guigang, Guangxi in 2002, and Li et al. found the rates were 66.0% and 29.5% for drivers and passengers respectively in two cities of Guangdong in 2005. We found the prevalence rates of helmet use on city streets were 96.8% for riders and 84.1% for their pillion passengers, indicating that in this developed region mandatory helmet use law and high enforcement activities achieved good compliance rates among the urban population, comparable to those of high income countries. However, riders on suburban and rural roads were less likely to wear a helmet despite legislation requiring helmet use on all road types. These results are consistent with previous research carried out in other middle income countries such as Malaysia (Kulanthayan et al., 2000), which found riders traveling in town areas were 6.5 times more likely to wear helmets when compared to those outside town areas, and Argentina (Ledesma & Peltzer, 2008), where riders in peripheral city areas were found to be 2.5 times less likely to wear a helmet when compared to those in center areas. The lower helmet wearing rates in rural regions found in our study are however not surprising. Enforcement activities are generally more limited in rural areas due to limited resources and staffing as well as the larger spatial coverage needed (Zwerling et al., 2005). Riders on county roads or provincial roads may therefore be less likely to wear helmets both because they may perceive less risks due to less traffic volume and due to a low level of police presence on these roads. Despite the high helmet wearing rates on urban roads, the riders in urban settings were more likely to wear non-standard helmets compared with those riding in rural areas. Most of nonmotorcycle helmets appeared to be ‘sun helmets’, characterized by a small coverage of the head, made of fragile plastic and without energy absorbing lining inside. Other helmets observed included the construction helmet or ‘combat’ helmet. For those helmets that appeared to be designed for motorcycles, we were unable to identify from our observations the helmet quality, and it is very likely that the proportion of non-standard helmet is higher than we have reported here. Zhang et al. (cited in Junhua et al., 2004) reported that in Guangxi non-standard products comprised 70% of the observed helmets. Although the national standard for motorcycle helmets (State Bureau of Quality & Technical Supervision, 1989) has been enacted since 1989, during the period of the survey the non-standard sun helmets, as cheap as 5–15 RMB (equal to 1–3 USD), were sold in most motorcycle shops or motorcycle repair shops in Zhongshan. It is likely that this kind of low cost helmet
without an energy absorbing lining can provide only very limited protection for the rider in the event of a serious crash. It has been reported that head injuries occur more frequently and are more severe among those riders wearing a non-standard helmet than those wearing a standard helmet (Peek-Asa et al., 1999). However, that study was conducted in the US where non-standard helmets may be better quality that ones commonly worn in China, so the impact of non-standard helmets may be even greater in China. Although there are regulations in Guangdong Province (Guangdong People’s Congress Committee, 2006) that require riders to wear helmets that meet the national standard, police enforcement activity rarely or never targets the standard of helmets but rather the use of helmets. This may due to perceived low priority of the task and also to the difficulty of determining helmet quality. The prevalence of correct use in the current study was 43.2% for drivers and 20.9% passengers respectively, indicating nearly 2 out of 5 riders with helmets either did not fasten or did not firmly fasten the chinstrap. Among all the riders observed, less than one-third were wearing standard helmets with the chinstrap being fastened. The finding was consistent with a survey in urban Indonesia, which found a “token compliance” among half of those who wore a helmet (Conrad et al., 1996), and the survey conducted in Shantou and Chaozhou (Liping et al., 2008), which found nearly 50% of riders with helmets did not fasten the chinstrap. Either incorrectly wearing the helmet or using a non-standard helmet indicates that the rider is not maximally protected by a helmet in the case of a crash. Besides road types and the position on the motorcycle (rider or passenger), observed helmet use was also associated with other factors such as gender, registration status, number of passengers and weather. The differences in helmet use of drivers by gender were not significant, but female passengers were significantly more likely to be helmet users than male passengers, a finding consistent with previous studies (Kulanthayan et al., 2000; Liping et al., 2008). This finding is also supported by other literature suggesting females are more likely to adopt safety behaviors compared with males (Ledesma & Peltzer, 2008). The motorcyclists riding an unregistered motorcycle are a specific high risk group (Haworth et al., 1994), therefore it was not surprising to find in the survey that these riders were less likely to wear helmets. The riders traveling on motorcycles with more passengers also had lower compliance, which may be due to the limited availability of helmets for multiple passengers. We also found the passengers were less likely to wear a helmet on a cloudy day than a sunny day, which was however inconsistent with previous studies (Gkritza, 2009). It is possible that in unfavorable weather the motorcyclists tend to ride a short trip, which is associated with non-use of helmets, or that they wear helmets on sunny days to protect themselves from the sun. However, this needs further investigation. This study has several limitations. Firstly, without stopping the motorcycle riders, there is some measurement bias associated with observations of helmet type, incorrect use and rider characteristics. Many helmets may appear to be standard helmets on visual inspection but in fact lack an energy absorption layer that may protect the rider from injury in the event of a crash. To reduce the observation bias we conducted observations whilst the motorcycle was stationary and the observers were comprehensively trained; nonetheless the prevalence of non-standard helmets may be under-estimated. Secondly, the observation was implemented in February (spring). It has been previously reported that the helmet wearing rate in summer with a hot and humid day was lower than that in winter (Junhua et al., 2004), so it is likely that the wearing rate may change by season. Thirdly, as the number of motorcycle ownership by region and Vehicle Miles of Travel (VMT) by road were not available, we selected the sites based on proportion of the population in urban and rural areas of the city. Although this means that we were unable to sample by sites by motorcycle exposure because
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there are a high number of motorcycles in the city this should not have resulted in significant bias in the estimates. Based on these findings, it can be concluded that the compliance rates appeared to be very high on city streets of this developed region, indicating the measures to increase helmet use are effective within the urban area. However the riders on urban roads were more likely to wear non-standard helmets and overall less than one-third of the motorcycle riders were maximally protected by a helmet. It is suggested that high visibility enforcement activities should be undertaken in rural areas and that enforcement needs to address both incorrect use and low quality of helmets. In addition, extensive public education programs need to be carried out targeting all riders, both drivers and passengers. Oversight of motorcycle helmet quality is the responsibility of the Bureau of Quality & Technical Supervision and the Administration for Industry & Commerce, rather than the traffic police. Strategies to facilitate joint action on enforcement of helmet quality may help to improve both the prevalence of helmet use and the quality of helmets worn in the region. Acknowledgements We thank all the observers who have contributed their holidays to the observation. Rebecca Ivers, Wei Du and Teresa Senserrick are supported by research fellowships from the National Health and Medical Research Council of Australia. References Ameratunga, S., Hijar, M., Norton, R., 2006. Road-traffic injuries: confronting disparities to address a global-health problem. Lancet 367, 1533–1540. Chesham, D.J., Rutter, D.R., Quine, L., 1993. Motorcycling safety research: a review of the social and behavioural literature. Soc. Sci. Med. 37 (3), 419–429. Conrad, P., Bradshaw, Y.S., Lamsudin, R., Kasniyah, N., Costello, C., 1996. Helmets, injuries and cultural definitions: motorcycle injury in urban Indonesia. Accid. Anal. Prev. 28 (2), 193–200.
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Prevalence rates of helmet use among motorcycle riders in a developed region in China Yu Xuequn a,∗ , Liang Ke a , Rebecca Ivers b , Wei Du a,b , Teresa Senserrick b a b
The George Institute for International Health, China, Beijing, China Injury Division, The George Institute for International Health, The University of Sydney, Australia
a r t i c l e
i n f o
Article history: Received 11 March 2010 Received in revised form 11 August 2010 Accepted 13 August 2010 Keywords: Motorcycle Helmet Epidemiology Road safety
a b s t r a c t This study aimed to determine the prevalence rates of helmet use, and of correct helmet use (chinstrap firmly fastened) among motorcycle riders and their passengers in Zhongshan, Guangdong Province, China. A cross-sectional survey involving direct observation of motorcycle riders was conducted at 20 randomly selected intersections. A total of 13,410 motorcycles were observed during a 10-day period in February 2009. The overall prevalence of helmet use was 72.6% (95% CI: 71.8–73.3%) among drivers and 34.1% (95% CI: 32.7–35.5%) among pillion passengers. The prevalence of correct use was 43.2% (95% CI: 42.4–44.0%) and 20.9% (95% CI: 19.8–22.1%) for drivers and passengers respectively. The helmet wearing rate on city streets was almost 95%, however city riders were more likely than rural riders to wear non-motorcycle helmets while riding. In multivariate analyses, factors associated with increased helmet use included riding on city streets, male gender, being a driver, carrying less passengers and riding a registered motorcycle. The results indicated enforcement and education activities need to be strengthened with respect to both helmet use and helmet quality, especially in rural areas, in order to improve wearing rates. © 2010 Elsevier Ltd. All rights reserved.
1. Introduction Road traffic injury in China is a significant public health issue. The Ministry of Public Security in China reports that from 2003 to 2007 the number of road fatalities in China was nearly 100,000 per year and the number of seriously injured nearly 500,000 (Traffic Administration Bureau of China Public Security Ministry, 2008). Road collisions are reported to be the main cause of death in China for those aged 45 years and below (World Health Organization, 2008). Due to increasing motor vehicle ownership associated with rapid economic development, without effective interventions the number of road traffic injuries are expected to be even more significant in the next decade (Ameratunga et al., 2006). Since the 1980s, due to the city governors’ concern about motorcycle related issues including road traffic injuries, pollution and traffic chaos, motorcycles have been restricted from travelling on public roads in large cities such as Beijing, Shanghai and more recently Guangzhou. However motorcycles, as a convenient and affordable means of transportation, are used extensively in small to medium cities and rural areas of southern China. The total number of motorcycles owned in China increased from 2.5 million (about
∗ Corresponding author at: Research & Development, The George Institute, China, Room 1302, Tower B, Horizon Plaza, No. 6 Zhichun Road, Haidian District, Beijing 100088, PR China. Tel.: +86 10 82800577x308; fax: +86 10 82800177. E-mail address: [email protected] (Y. Xuequn). 0001-4575/$ – see front matter © 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.aap.2010.08.012
23% of total motorized vehicles) in 1987 to 50 million (about 70%) in 2002, and to 70 million (about 54%) in 2005 (National Bureau of Statistics, 2006). In accordance with this increase, the proportion of traffic fatalities sustained by motorcyclists also increased significantly from 7.5% in 1987 to 18.9% in 2001 (Zhang et al., 2004), and to 22.2% in 2007 (Traffic Administration Bureau of China Public Security Ministry, 2008). The proportion of traffic fatalities is even higher in some areas where motorcycle use is more common, for example 43.0% of total traffic fatalities in Guangzhou prior to the restrictions (Li, 2006 September 20). Motorcycle helmets decrease head injuries in a crash by about 70% and death by about 40% (Liu et al., 2009), and reduce the length of hospital stay and the medical costs of injured riders (Chesham et al., 1993). The Regulation of Road Traffic Administration which came into effect in March 1988 made helmet usage mandatory for all two-wheeled motorcycle riders in China (The State Council of the People’s Republic of China, 1988). Under the Road Traffic Safety Law of the People’s Republic of China which was enacted from May 2004, the penalty for not wearing a safety helmet was raised from 5 RMB (less than 1 USD) to 20–200 RMB (about 3–30 USD). However, despite the existing legislation and penalties in China, the reported rates of helmet use have remained low, with estimates ranging from 30% to 60% (Junhua et al., 2004; Liping et al., 2008). Even with national legislation, helmet usage rates and pattern may vary widely from one region to the next depending on educational level, penalty charge and enforcement activities (World Health Organization, 2006). Few previous studies have been
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conducted in the developed regions of China, currently experiencing rapid motorization. In order to examine the prevalence rates and pattern of helmet use in these regions, we conducted roadside observations in Zhongshan city, a typical economically developed region in Southern China. 2. Methods 2.1. Location This study was conducted in February 2009 in a southern prefecture-level city of China, Zhongshan, which is situated in the Pearl River Delta, with an area of 1679 km2 and a population of 2.49 million. It is composed of 5 districts (and Xiao Lan town) that can be classified as urban locations and 17 towns classified as rural locations. In 2008 the city ranked 15th in a list of more than 200 cities in China by per capita income. In November 1999, to restrict the increasing number of motorcycles, the Zhongshan government ceased registration of new motorcycles plates. The number of registered motorcycles has thus remained constant at approximately 350,000 (Zhongshan Statistic Bureau, 2009), with approximately 1 in 7 citizens owning a motorcycle. However this number does not include the unregistered motorcycles. 2.2. Roadside observation In February 2010, a cross-sectional on-site observational survey was implemented based on a random sample of the road hierarchy in the city. At each of 20 randomly selected observation sites, data was collected for 3 separate hours at daytime (7 am–7 pm). 2.2.1. Site selection To select the roadside sites, a grid with sections measuring 2 cm by 2 cm was placed over a standard map of Zhongshan and drawn to a scale of 1 cm = 1.85 km. Each grid box contained an area of approximately 3.42 km2 . The grid dimensions were 26 lines horizontally and 18 lines vertically. Each valid grid box containing at least one intersection in an included part of Zhongshan was numbered. The selection of sites was based on proportion of the population in urban and rural areas of the city to avoid the sites over representing the non-urban areas. In this way 8 sites from urban areas (including 4 districts and Xiao Lang town) and 12 sites from rural areas were selected. Random numbers were generated to select grid boxes from which specific intersections were selected. For each site an alternate site was also selected randomly from the box as a backup. Researchers visited and evaluated each site prior to the study to determine whether the site was suitable for the observation. The availability of traffic lights or stop signs and safety of observers were the main considerations. If the original site did not meet the requirements, the researchers would visit and evaluate the alternate site. If neither the original site nor the alternate site met the requirements, the researchers then identified another suitable site that was closest to the original site (the third site). Among the 20 observational sites, 9 alternate sites and 1 third site were used. The day of week and time of day for site observation were randomly assigned to sites in such a way that all days of the week and all daylight hours (7 am–7 pm) had equal probability of selection. 2.2.2. Observation techniques All the observations were undertaken whilst the motorcycle was stationary. The observers conducted their roadside observations solely at intersections controlled by a stop sign or stoplight, recording information of gender, helmet use, whether the chinstrap was fastened and helmet type of motorcycle riders. Registration status of the motorcycle was collected, and this was determined by whether a registration plate was displayed on the front and/or
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rear of the vehicle. Mopeds, electric scooters and motor scooters less than 50 cc were excluded from observations because it is not mandatory for the riders of these vehicles to use a helmet. Helmet designs were classified as full face, open face, half face and those not designed for motorcycle use (non-motorcycle helmet), such as ‘sun helmet’, construction helmet, combat helmet and others (see Fig. 1 for examples). Helmet use was classified as ‘correct use’ (chinstrap firmly fastened), ‘incorrect use’ (chinstrap not firmly fastened or not fastened) and ‘no helmet use’. Road types were classified as ‘city street’, ‘county road’, ‘provincial road’ and ‘national road’ according to designations from the city authorities. The “city street” is unique to the urban settings and the other 3 types of road are characteristic of rural settings. 2.2.3. Observers training and audits Observers were recruited from local colleges. Prior to data collection, the 10 field observers attended 1 day of intensive training and were trained in techniques to observe the correct use of helmets at the roadside observational sites. The observers worked in teams of two, observing the same motorcycle and recording data independently on separate data collection forms. Teams were rotated throughout the training to ensure that each observer was paired with every other observer. The inter-observer reliability for each pair of observers was at least 85% for both observed drivers and passengers. On-site audits were made by the researchers during data collection to ensure adherence to study protocols. 2.3. Ethical issues Ethical approval for this study was obtained from the Human Ethics Committee of Peking University Health Science Center. No identifying information of riders was collected in the roadside observation. 2.4. Statistical analysis SAS version 9.1 (SAS Institute, Cary, NC) was used to conduct all data analyses, which were stratified by mode of travel, i.e., motorcycle riders or passengers. Frequencies, proportions and their associated 95% confidence intervals (CI) for helmet use and helmet correct use by variables including sex, day of week, time of day, road type, number of passengers or additional passengers, weather, and registration status were calculated. The Chi-square test was used to examine the proportional difference between road types, where appropriate. Multivariate logistic regression was further used to estimate the adjusted odds ratio (OR) with 95% confidence limits (95% CI) of helmet use for variables of interest including sex, day of week, time of day, road type, number of passengers/additional passengers, weather, and licence status. p-Values less than 0.05 were defined as statistically significant. 3. Results A total of 13,410 drivers and 4498 passengers were observed at the 20 randomly selected sites. Where gender was able to be estimated, as shown in Tables 1 and 2, of the observed drivers 10,629 were men and 2776 were women (male:female ratio 3.83), while of the observed passengers, 1847 were men and 2394 women (male:female ratio 0.77). Of the observed motorcycles, 9321 (69.5%) had no pillion passenger, 3694 (27.6%) carried one pillion passenger, and 395 (2.9%) carried two or more pillion passengers. Of all observed pillion passenger, 225 (5.0%) were recorded as children younger than 12 years of age. Most (99.3%) observed motorcycles were recorded as registered. The prevalence of helmet use for drivers was 72.6% (95% CI: 71.8–73.3%) compared with 34.1% (95% CI: 32.7–35.5%) for pillion
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Fig. 1. Examples of non-motorcycle helmets. Table 1 Characteristics of motorcycle drivers in Zhongshan, China, 2009.
Drivers Sex Male Female Weekday Workday Weekend Time 7:009:0017:00–19:00 Road type City street County road Provincial road National road No. of passengers No passenger One passenger ≥Two passengers Weather Sunny Cloudy Rain Registered Yes No
N (%)
Helmet wearing rate (%)
95% CI
Correctly wearing rate (%)
95% CI
13,410
72.6
71.8–73.3
43.2
42.4–44.0
10,629 (79.3) 2776 (20.7)
72.1 74.5
71.2–72.9 72.8–76.1
41.3 50.4
40.4–42.2 48.5–52.2
9967 (74.3) 3443 (25.7)
72.8 72.0
71.9–73.7 70.4–73.4
43.4 42.6
42.4–44.4 41.0–44.3
695 (5.2) 12,103 (90.3) 612 (4.6)
65.8 72.1 89.1
62.2–69.3 71.3–72.9 86.6–91.5
37.4 43.0 54.3
33.8–41.0 42.1–43.8 50.3–58.2
2627 (19.6) 4099 (30.6) 2711 (20.2) 3973 (29.6)
96.8 65.0 74.6 63.0
96.1–97.4 63.5–66.4 73.0–76.2 61.5–64.5
60.3 36.6 45.0 37.4
58.4–62.1 35.1–38.1 43.1–46.9 35.9–38.9
9321 (69.5) 3694 (27.6) 395 (2.9)
74.7 68.1 63.3
73.8–75.6 66.6–69.6 58.5–68.0
43.9 41.6 40.0
42.9–45.0 40.0–43.2 35.2–44.8
6102 (45.8) 6923 (52.0) 290 (2.2)
73.4 71.7 67.2
72.3–74.5 70.6–72.7 61.8–72.6
45.5 41.2 40.3
44.2–46.7 40.0–42.4 34.7–46.0
13,257 (99.3) 100 (0.7)
72.9 22.0
72.2–73.7 13.9–30.1
43.4 11.0
42.6–44.3 0.5–17.1
95% CI
Correctly wearing rate (%)
Table 2 Characteristics of motorcycle passengers in Zhongshan, China, 2009. N (%) Passengers Sex Male Female Weekday Workday Weekend Time 7:009:0017:00–19:00 Road type City street County road Provincial road National road No. of passengers One passenger ≥Two passengers Weather Sunny Cloudy Rain Registered Yes No
Helmet wearing rate (%)
95% CI
4498 (100)
34.1
32.7–35.5
20.9
19.8–22.1
1847 (43.5) 2394 (56.4)
30.1 40.6
28.0–32.2 38.6–42.6
16.4 26.7
14.7–18.0 24.9–28.4
3074 (68.3) 1424 (31.7)
35.7 30.6
34.0–37.4 28.2–33.0
22.4 17.8
20.9–23.9 15.9–19.8
190 (4.2) 4157 (92.4) 151 (3.4)
28.4 33.4 60.3
22.0–34.8 32.0–34.8 52.5–68.1
18.4 20.4 39.7
12.9–23.9 19.2–21.6 31.9–47.5
609 (13.5) 1464 (32.6) 1013 (22.5) 1412 (31.4)
84.1 23.6 38.0 20.6
81.2–87.0 21.4–25.7 35.0–41.0 18.5–22.7
54.7 13.9 22.3 12.7
50.7–58.6 12.2–15.7 19.8–24.9 10.9–14.4
3694 (82.1) 804 (17.9)
40.2 6.0
38.6–41.8 4.3–7.6
24.6 4.1
23.2–26.0 2.7–5.5
2060 (46.2) 2292 (51.4) 109 (2.4)
36.9 31.5 18.4
34.8–39.0 29.6–33.5 11.1–25.6
23.3 19.1 10.1
21.5–25.1 17.5–20.7 0.4–15.8
4435 (99.2) 37 (0.8)
34.2 0.8
32.8–35.6 0.0–16.9
21.1 0.0
19.9–22.3 0.0–0.0
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Table 3 Results of logistic regression analysis of predictors associated with non-helmet use among motorcycle drivers and passengers in Zhongshan, China 2009.
Driver
Passenger
Road type City street County road Provincial road National road No. of passengers 0 1 ≥2 Sex Male Female Time 7:009:0017:00–19:00 Registration Yes No Weather Sunny Cloudy Rainy Weekday Monday–Friday Saturday–Sunday Road type City street County road Provincial road National road Additional passengers 0 ≥1 Sex Male Female Time 7:009:0017:00–19:00 Registration Yes No Weather Sunny Cloudy Rainy Weekday Monday–Friday Saturday–Sunday
OR
Lower CI
Upper CI
p-Value
Reference 15.51 9.68 16.93
12.31 7.63 13.44
19.54 12.28 21.32
<.0001 <.0001 <.0001
Reference 1.27 1.41
1.16 1.13
1.38 1.75
<.0001 0.002
Reference 1.07
0.96
1.18
0.228
Reference 1.10 0.93
0.93 0.66
1.30 1.29
0.265 0.646
Reference 12.26
7.21
20.84
Reference 1.08 0.88
0.98 0.68
1.18 1.15
0.122 0.353
Reference 1.03
0.93
1.15
0.530
Reference 26.60 13.21 30.80
19.32 9.55 22.28
36.63 18.29 42.56
<.001 <.001 <.001
Reference 12.79
8.98
18.21
<.001
Reference 0.60
0.51
0.70
<.001
Reference 1.55 0.87
0.78 0.49
1.10 1.53
0.607 0.620
Reference 8.57
2.22
33.08
0.002
Reference 1.30 1.46
1.09 0.85
1.552 2.50
0.004 0.167
Reference 0.95
0.78
1.15
0.567
passengers. Rates of correct helmet use were lower, being 43.2% (95% CI: 42.4–44.0%) for drivers and 20.9% (95% CI: 19.8–22.1%) for passengers respectively. The prevalence of helmet use on city streets was 96.8% and 84.1% for drivers and pillion passengers respectively, while the rates were much lower for other road types. Multivariate analyses (Table 3) showed that the strongest predictor for helmet use among drivers was the type of road they were traveling on. Compared to drivers on city streets, the adjusted OR for unhelmeted drivers was 15.51 (95% CI: 12.31–19.54), 9.68 (95% CI: 7.63–12.28) and 16.93 (95% CI: 13.44–21.32) for national, provincial and county roads respectively. Helmet use among drivers was also significantly associated with number of passengers and registration status. Drivers riding a registered motorcycle and with fewer passengers were more likely to wear a helmet than those with an unregistered motorcycle and with more passengers. There was also a statistically significant impact of road type, number of additional passengers and registration status on helmet use among passen-
<.0001
gers. In addition, helmet use among passengers was also associated with gender and weather, i.e., helmet use among male passengers was significantly lower than that of female passengers (adjusted OR = 0.60, 95% CI: 0.51–0.70), and passengers riding on a cloudy day were less likely to be wearing a helmet than those on sunny days (adjusted OR = 1.30, 95% CI: 1.09–1.55). No statistically significant association was found for helmet use with the time or weekday of observation. Among the 13,410 drivers and 4233 passengers observed, 1676 (12.5%) and 643 (15.2%) were wearing non-motorcycle helmets. Only 4965 (37.0%) drivers and 548 (12.9%) passengers were wearing helmets designed for motorcyclists that were properly secured (data not shown). There were statistically significant relationships between types of helmet use and road types traveled (for drivers, 2 = 603.9, p < 0.001; for passengers, 2 = 758.7, p < 0.001). Fig. 2 shows the highest proportion of people wearing non-standard helmets was those traveling on city streets (28.1% for drivers and 60.4% for passengers respectively).
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Fig. 2. Characteristics of helmet type among motorcycle drivers and passengers by road type in Zhongshan, China, 2009.
4. Discussion This study found that the overall prevalence of helmet use in Zhongshan was 72.6% among drivers and 34.1% among pillion passengers. The crude usage rate of 62.0% for all riders (drivers and passengers) was higher than the results of two previous surveys in less developed regions of China (Junhua et al., 2004; Liping et al., 2008). Zhang et al. found that helmet wearing rates were 56.2% for the riders in Guigang, Guangxi in 2002, and Li et al. found the rates were 66.0% and 29.5% for drivers and passengers respectively in two cities of Guangdong in 2005. We found the prevalence rates of helmet use on city streets were 96.8% for riders and 84.1% for their pillion passengers, indicating that in this developed region mandatory helmet use law and high enforcement activities achieved good compliance rates among the urban population, comparable to those of high income countries. However, riders on suburban and rural roads were less likely to wear a helmet despite legislation requiring helmet use on all road types. These results are consistent with previous research carried out in other middle income countries such as Malaysia (Kulanthayan et al., 2000), which found riders traveling in town areas were 6.5 times more likely to wear helmets when compared to those outside town areas, and Argentina (Ledesma & Peltzer, 2008), where riders in peripheral city areas were found to be 2.5 times less likely to wear a helmet when compared to those in center areas. The lower helmet wearing rates in rural regions found in our study are however not surprising. Enforcement activities are generally more limited in rural areas due to limited resources and staffing as well as the larger spatial coverage needed (Zwerling et al., 2005). Riders on county roads or provincial roads may therefore be less likely to wear helmets both because they may perceive less risks due to less traffic volume and due to a low level of police presence on these roads. Despite the high helmet wearing rates on urban roads, the riders in urban settings were more likely to wear non-standard helmets compared with those riding in rural areas. Most of nonmotorcycle helmets appeared to be ‘sun helmets’, characterized by a small coverage of the head, made of fragile plastic and without energy absorbing lining inside. Other helmets observed included the construction helmet or ‘combat’ helmet. For those helmets that appeared to be designed for motorcycles, we were unable to identify from our observations the helmet quality, and it is very likely that the proportion of non-standard helmet is higher than we have reported here. Zhang et al. (cited in Junhua et al., 2004) reported that in Guangxi non-standard products comprised 70% of the observed helmets. Although the national standard for motorcycle helmets (State Bureau of Quality & Technical Supervision, 1989) has been enacted since 1989, during the period of the survey the non-standard sun helmets, as cheap as 5–15 RMB (equal to 1–3 USD), were sold in most motorcycle shops or motorcycle repair shops in Zhongshan. It is likely that this kind of low cost helmet
without an energy absorbing lining can provide only very limited protection for the rider in the event of a serious crash. It has been reported that head injuries occur more frequently and are more severe among those riders wearing a non-standard helmet than those wearing a standard helmet (Peek-Asa et al., 1999). However, that study was conducted in the US where non-standard helmets may be better quality that ones commonly worn in China, so the impact of non-standard helmets may be even greater in China. Although there are regulations in Guangdong Province (Guangdong People’s Congress Committee, 2006) that require riders to wear helmets that meet the national standard, police enforcement activity rarely or never targets the standard of helmets but rather the use of helmets. This may due to perceived low priority of the task and also to the difficulty of determining helmet quality. The prevalence of correct use in the current study was 43.2% for drivers and 20.9% passengers respectively, indicating nearly 2 out of 5 riders with helmets either did not fasten or did not firmly fasten the chinstrap. Among all the riders observed, less than one-third were wearing standard helmets with the chinstrap being fastened. The finding was consistent with a survey in urban Indonesia, which found a “token compliance” among half of those who wore a helmet (Conrad et al., 1996), and the survey conducted in Shantou and Chaozhou (Liping et al., 2008), which found nearly 50% of riders with helmets did not fasten the chinstrap. Either incorrectly wearing the helmet or using a non-standard helmet indicates that the rider is not maximally protected by a helmet in the case of a crash. Besides road types and the position on the motorcycle (rider or passenger), observed helmet use was also associated with other factors such as gender, registration status, number of passengers and weather. The differences in helmet use of drivers by gender were not significant, but female passengers were significantly more likely to be helmet users than male passengers, a finding consistent with previous studies (Kulanthayan et al., 2000; Liping et al., 2008). This finding is also supported by other literature suggesting females are more likely to adopt safety behaviors compared with males (Ledesma & Peltzer, 2008). The motorcyclists riding an unregistered motorcycle are a specific high risk group (Haworth et al., 1994), therefore it was not surprising to find in the survey that these riders were less likely to wear helmets. The riders traveling on motorcycles with more passengers also had lower compliance, which may be due to the limited availability of helmets for multiple passengers. We also found the passengers were less likely to wear a helmet on a cloudy day than a sunny day, which was however inconsistent with previous studies (Gkritza, 2009). It is possible that in unfavorable weather the motorcyclists tend to ride a short trip, which is associated with non-use of helmets, or that they wear helmets on sunny days to protect themselves from the sun. However, this needs further investigation. This study has several limitations. Firstly, without stopping the motorcycle riders, there is some measurement bias associated with observations of helmet type, incorrect use and rider characteristics. Many helmets may appear to be standard helmets on visual inspection but in fact lack an energy absorption layer that may protect the rider from injury in the event of a crash. To reduce the observation bias we conducted observations whilst the motorcycle was stationary and the observers were comprehensively trained; nonetheless the prevalence of non-standard helmets may be under-estimated. Secondly, the observation was implemented in February (spring). It has been previously reported that the helmet wearing rate in summer with a hot and humid day was lower than that in winter (Junhua et al., 2004), so it is likely that the wearing rate may change by season. Thirdly, as the number of motorcycle ownership by region and Vehicle Miles of Travel (VMT) by road were not available, we selected the sites based on proportion of the population in urban and rural areas of the city. Although this means that we were unable to sample by sites by motorcycle exposure because
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there are a high number of motorcycles in the city this should not have resulted in significant bias in the estimates. Based on these findings, it can be concluded that the compliance rates appeared to be very high on city streets of this developed region, indicating the measures to increase helmet use are effective within the urban area. However the riders on urban roads were more likely to wear non-standard helmets and overall less than one-third of the motorcycle riders were maximally protected by a helmet. It is suggested that high visibility enforcement activities should be undertaken in rural areas and that enforcement needs to address both incorrect use and low quality of helmets. In addition, extensive public education programs need to be carried out targeting all riders, both drivers and passengers. Oversight of motorcycle helmet quality is the responsibility of the Bureau of Quality & Technical Supervision and the Administration for Industry & Commerce, rather than the traffic police. Strategies to facilitate joint action on enforcement of helmet quality may help to improve both the prevalence of helmet use and the quality of helmets worn in the region. Acknowledgements We thank all the observers who have contributed their holidays to the observation. Rebecca Ivers, Wei Du and Teresa Senserrick are supported by research fellowships from the National Health and Medical Research Council of Australia. References Ameratunga, S., Hijar, M., Norton, R., 2006. Road-traffic injuries: confronting disparities to address a global-health problem. Lancet 367, 1533–1540. Chesham, D.J., Rutter, D.R., Quine, L., 1993. Motorcycling safety research: a review of the social and behavioural literature. Soc. Sci. Med. 37 (3), 419–429. Conrad, P., Bradshaw, Y.S., Lamsudin, R., Kasniyah, N., Costello, C., 1996. Helmets, injuries and cultural definitions: motorcycle injury in urban Indonesia. Accid. Anal. Prev. 28 (2), 193–200.
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