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Traffic Injury Prevention Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/gcpi20
Correlates and Barriers associated with Motorcycle Helmet use in Wa, Ghana a
a
a
Millicent Awialie Akaateba , Ibrahim Yakubu & Bernard AfiikAkanpabadai Akanbang a
Department of Planning and Management, FPLM, University for Development Studies Wa, Ghana Accepted author version posted online: 20 Mar 2015.
Click for updates To cite this article: Millicent Awialie Akaateba, Ibrahim Yakubu & Bernard AfiikAkanpabadai Akanbang (2015): Correlates and Barriers associated with Motorcycle Helmet use in Wa, Ghana, Traffic Injury Prevention, DOI: 10.1080/15389588.2015.1024833 To link to this article: http://dx.doi.org/10.1080/15389588.2015.1024833
Disclaimer: This is a version of an unedited manuscript that has been accepted for publication. As a service to authors and researchers we are providing this version of the accepted manuscript (AM). Copyediting, typesetting, and review of the resulting proof will be undertaken on this manuscript before final publication of the Version of Record (VoR). During production and pre-press, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal relate to this version also.
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
ACCEPTED MANUSCRIPT Correlates and Barriers associated with Motorcycle Helmet use in Wa, Ghana
Millicent Awialie AKAATEBA1, Ibrahim YAKUBU, Bernard AfiikAkanpabadai AKANBANG
Downloaded by [University of Nebraska, Lincoln] at 15:11 07 April 2015
Department of Planning and Management, FPLM, University for Development Studies Wa, Ghana
1
Corresponding author’s address: Department of Planning and Management, FPLM, University
for Development Studies, UPW 3, Wa, Ghana. Email Address: [email protected] / [email protected]
ABSTRACT Objective: This study was conducted to investigate the correlates and barriers to helmet use among motorcycle riders in Wa, a motorcycle predominant town in Ghana. An additional objective was to find out the association between helmet use and riders’ knowledge, attitudes and beliefs towards helmets. Methods: Cross-sectional surveys comprising both observation of helmet use and interviews were conducted among motorcycle riders at six randomly selected fuel stations and four
1
ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT motorcycle service centres within and outside the Central Business District of Wa. Questions covered riders’ socio-demographic and riding characteristics, helmet use, reasons for use or nonuse of helmets, and knowledge, attitudes and beliefs about helmets. Analyses were based on frequencies and testing of strength of association using adjusted odds ratios (with 95%
Downloaded by [University of Nebraska, Lincoln] at 15:11 07 April 2015
confidence intervals) in Binary Logistic Regression. Results: The prevalence of helmet use among the 271 sampled riders was 46% (95% CI: 40.252.0). Gender, age, marital status and occupation were significant socio-demographic correlates of helmet use in Wa. Compared to currently married riders, unmarried riders were 5times less likely to use a helmet. No significant association existed between riders’ educational attainment and helmet use. Helmet use was also positively correlated with helmet ownership and license holding. The leading reasons stated for helmet non-use among non-users were, not travelling on a long distance and helmets block vision and hearing. Protection from injury, legal requirement, and coping with the police for fear of being accosted for helmet non-use were identified as common reasons for helmet use. Positive attitudes and beliefs were also significantly correlated with helmet use. Conclusions: Despite the existence of a legislation mandating the use of helmets on all roads as well as the high level of awareness among riders on this legislation and the benefits of helmets, the incidence of helmet use among motorists continue to be low in Wa, Ghana. This means that efforts to identify strategies to increase helmet use need to continue. The evidence provided by this study suggests that stakeholders in road safety need to put in interventions to ensure a rigorous enforcement of the helmet use legislation and improvement in helmet design. These
2
ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT should be combined with the development of targeted educational programs with the aim of changing unfavorable attitudes and beliefs towards helmet use.
Downloaded by [University of Nebraska, Lincoln] at 15:11 07 April 2015
KEYWORDS: Motorcycle riders; attitudes; factors; helmet; legislation; Northern Ghana
INTRODUCTION Injuries and deaths resulting from road traffic crashes are a growing public health concern in many developing countries. The majority of these deaths and injuries occur among “vulnerable road users” – pedestrians, pedal cyclists, motorcyclists and other two-wheeler users (Peden et al. 2004). Whilst in developed countries, a great proportion of road traffic fatalities involve fourwheeled vehicles with motorcyclists comprising between 5% and 18% of road traffic injury deaths, in developing countries, motorized two-wheelers account for a significant proportion. Motorcyclists comprise up to a third of all road fatalities in the South-East Asia and Western Pacific Regions (Peden et al. 2004; WHO 2013). Due to their relatively low cost, convenience, and ability to manoeuvre on congested roads, in middle and low-income countries, motorcycles are increasingly becoming a popular mode of transport and a fast growing segment of vehicular traffic (WHO 2006). This has raised great concern about the safety features of the motorcycle and rider attitudes and behaviours in recent time. Motorcycles constitute the most risky form of motorized transport. They offer very little protection for riders and passengers. Studies have revealed that riders of motorized two- wheeled
3
ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT vehicles have higher risks of accidents, injuries and deaths compared to users of other modes of transport (Koornstra et al. 2003; Huang and Preston 2004; Dandona et al. 2006; Elliott et al. 2007; Janmohammadi et al. 2009). Koornstra et al. (2003) estimated that per 100 million-person travelling hours, 25 car-driver fatalities occur compared to 440 motorized two-wheeled vehicle rider fatalities. Injuries to the head-neck region are the most frequent injuries suffered by
Downloaded by [University of Nebraska, Lincoln] at 15:11 07 April 2015
motorcyclists and the primary cause of death and disability in motorcycle-related traffic accidents (Liu et al. 2008; WHO 2013). Head injuries contribute up to 75% of deaths among two-wheeled vehicle users in European countries and to as high as 88 percent in some developing countries (WHO 2013). Instinctively, wearing standard motorcycle helmets could reduce the number of such head injuries and resulting deaths. The effectiveness of safety helmets in preventing and reducing the severity of head injuries as well as deaths and cost resulting from motorcycle crashes have been extensively studied and documented in literature (see Rowland et al. 1996; Christian et al. 2003; Hundley et al. 2004; Keng 2005; Sauter et al. 2005; O’Connor 2005; Norvell and Cummings 2005; Liu et al. 2008; Houston and Richardson 2008; Moskal et al. 2008; NHTSA, 2008; Cui et al. 2009). From a meta-analysis, Liu et al. (2008) concluded that helmet use reduces the risk of head injury by around 69% and death by around 42%. Chiu et al. (2000) identified that riders without safety helmets were twice as likely to receive a head injury compared to helmeted riders. Another metaanalysis study by MacLeod et al. (2010) that combined findings from several independent studies also concluded that the use of motorcycle helmets decreases the overall death rate of motorcycle crashes, reduces the incidence of lethal head injury and decreases the severity of nonlethal head injury in motorcycle crashes among helmeted riders compared with non-helmeted riders. The
4
ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT existence of mandatory universal helmet laws have also been established to increase helmet wearing rates (Ichikawa et al. 2003; Servadei et al. 2003; Karkhaneh et al. 2006; Houston 2007), leading to a reduction in mortality and head injury in geographical areas with the law when compared with areas without it (MacLeod et al. 2010). Despite the established benefits of safety helmets, many studies have revealed that helmet use among motorcyclists is low in many low
Downloaded by [University of Nebraska, Lincoln] at 15:11 07 April 2015
and middle income countries such as Greece (Germeni et al. 2009), Vietnam (Hung et al. 2006), Brazil (Liberatti et al. 2003), Thailand (Pitaktong et al. 2004), Pakistan (Khan et al. 2008), India (Sreedharan et al. 2010), Nigeria (Oginni et al. 2007), Malaysia (Kulanthayan et al. 2000), China (Xuequn et al. 2011), Iran (Ali et al. 2011) and Ghana (Akaateba et al. 2014; Ackaar and Afukaar 2010). Besides the existence of national legislations mandating motorcycle helmet use, many other correlates or factors have been widely established in literature to be associated with helmet use. These include age and gender (Hurt et al. 1981; Ichikawa et al. 2003; Mangus et al. 2004; Nakahara et al. 2005; Hung et al. 2006; Li et al. 2008; Ackaar and Afukaar 2010; Xuequn et al. 2011; Papadakaki et al. 2013); educational attainment (Hurt et al. 1981; Khan et al. 2008; Hung et al. 2008; Ranney et al. 2010); motorcyclists’ position on the motorbike, the time of day, day of week and location or type of road travelled on (Skalkidou et al. 1999; Nakahara et al. 2005; Xuequn et al. 2011; Bachani et al. 2012; Akaateba et al. 2014). Other factors such as travel distance; (Ouellet, 2011; Kulanthayan et al. 2000; Hung et al. 2008); weather condition (Skalkidou et al. 1999; Ledesma and Peltzer 2008; Gkritza 2009; Ledesma et al. 2014); history of a motorcycle accident or injury (Mangus et al. 2004; Pitaktong et al. 2004; Ranney et al. 2010; Siviroj, 2012); possession of a rider’s license (Reeder et al.1997; Kulanthayan et al. 2000),
5
ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT embarrassment (Moghisi et al 2014a; 2014b) as well as helmet features and rider perceptions (Hung et al. 2008; Kennedy et al. 2011; Bogerd et al. 2011; Orsi et al. 2012) have been identified to be associated with helmet use. These studies have generally concluded that helmet non-use is significantly correlated with young riders, male riders, less educated riders, pillion riders, riding at night time, riding on weekends and on rural and secondary roads, travelling on short distances,
Downloaded by [University of Nebraska, Lincoln] at 15:11 07 April 2015
good weather conditions, previous involvement in motorcycle accident, unlicensed riders and negative perceptions of helmet features and their associated discomfort. Other studies have established that riders’ knowledge, beliefs and attitudes towards helmets have significant influence on helmet use. Knowledge and beliefs about helmet safety and injury prevention act as a catalyst for helmet use whilst motorcyclists negative attitudes and beliefs about helmet features such as limited vision and hearing, discomfort and cost of helmets act as major barriers to helmet use (WHO 2006; Hung et al. 2008; Khan et al. 2008, Li et al. 2008; Ranney et al. 2010; Bachani et al. 2012; Papadakaki et al. 2013). In Ghana, motorcycles are a common mode of transport, particularly in rural areas. However, in recent time, they are increasingly becoming popular in many cities as an economical alternative mode of transport in congested road networks. Between 2000 and 2010, motorcycles registered in Ghana increased by more than five times, from 6,440 registered motorcycles in 2000 to 36,097 vehicles in 2010. Between 2010 and 2012, registered motorcycles almost doubled to 60,262 (DVLA 2013). This increase in motorcycles was accompanied by a corresponding increase in motorcycle fatalities and injuries. In absolute terms, motorcycle fatalities increased lamentably by 430% between 2000 and 2010. Consequently, motorcyclists fatalities as a proportion of the total road fatalities recorded in the country increased from 2% in 2000 to 9% in 2010 and to 15%
6
ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT in 2012 (NRSC 2012). In the northern part of Ghana, motorcycles are the most common form of transport providing mobility to millions of people as well as goods. Almost every urban household anecdotally in Northern Ghana owns a motorcycle. As a result, motorcycle riding is one of the activities every young adult must learn to do. The dominance of the motorcycle in northern Ghana has made it the major cause of traffic-related morbidity and mortality in these
Downloaded by [University of Nebraska, Lincoln] at 15:11 07 April 2015
areas, thus constituting a major economic burden to the country (Kudebong et al. 2011). In the Wa Municipality where this study is situated, motorcycles represented 98% of the total registered vehicles in the Municipality in 2012 and accounted for 80% of road fatalities (NRSC 2012). Although Section 16 (1) of the Ghana Road Traffic Act, 2004 (ACT 683) mandates the wearing of motorcycle helmets by both riders and pillion riders, helmet use in Wa is low among motorcyclists (Akaateba et al. 2014). The dominance of the motorcycle as a mode of transport coupled with the low helmet use among riders and the resulting significant proportion of road traffic fatalities associated with motorcyclists in the Wa Municipality make a study into helmet use and its associated factors germane. The few existing scientific studies on helmet use in northern Ghana (Ackaar and Afukaar 2010; Akaateba et al. 2014) have largely focused on establishing the prevalence of helmet use among motorcyclists through observational surveys. However, besides determining the frequency of helmet use, there is the need to understand the factors associated with its use as well as motorcyclists prevailing knowledge, attitudes and beliefs around helmet use. This is particularly important so that appropriate and focused measures and interventions can be formulated and implemented to improve helmet use considering the daily accidents and serious injuries sustained by unhelmeted motorcyclists in the Wa Municipality. The aim of this paper
7
ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT therefore is to examine the correlates and barriers as well as motorcyclists’ knowledge, attitudes and beliefs associated with helmet use. This study is a follow up to an earlier study by Akaateba et al. (2014) on helmet use prevalence. It will add new evidence and information on helmet use in Wa and aid in policy formulation for motorcycle injury prevention in the country. The study is particularly relevant and opportune in the light of general calls from road safety activists for the
Downloaded by [University of Nebraska, Lincoln] at 15:11 07 April 2015
National Road Safety Commission to develop effective interventions towards reducing the undesirable proportion of motorcycle fatalities and injuries in the Wa Township. The study generates useful evidence to assist in the development of evidence-based interventions tailored towards motorcycle helmet use.
METHODS The study adopted a cross sectional survey approach to obtain information from a random sample of motorcycle riders in Wa, Ghana. The data for this study were collected as part of a week-long study on helmet use in June 2013. Wa doubles as the capital of the Upper West Region (the youngest region in Ghana) and the Wa Municipality. It has a total population of 78,993 as per the 2010 Population and Housing Census and is a motorcycle-predominant town. Anecdotal evidence suggests that there exist at least one motorcycle in almost every home in the Wa Township.
The data collection approach for the study involved both observation of helmet use and interviews on helmet use barriers, knowledge, attitudes and practices. The study sites comprised of fuel stations and motorcycle service centers located along major routes leading to the Central
8
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ACCEPTED MANUSCRIPT Business District (CBD). These sites were first categorized into two: sites within the CBD of Wa (≤1km) and sites outside the CBD of Wa (>1km). Using a simple random sampling strategy, 6 fuel stations (3 from each category) were randomly selected from the 11 eligible fuel stations. Four motorcycle service centres comprising two within and two outside the CBD of Wa were
Downloaded by [University of Nebraska, Lincoln] at 15:11 07 April 2015
also randomly selected.
At each fuel station or motorcycle service centre, trained research assistants approached at random motorcycle riders who had stopped to refuel or to service their motorcycles to explain the purpose of the survey to them and obtain their consent. Where a motorcycle rider consented to the survey (about 8 in 10 motorcyclists approached agreed to participate) the research assistants recorded the rider’s use or non-use of a helmet and proceeded to conduct a face-to-face interview using a semi-structured questionnaire that was piloted on 20 riders at two sites within and outside the CBD. The respondents were not aware of being observed as the research assistants did the observation of the safety helmet use from a distance before approaching them. The survey covered only motorcycle riders. Pillion riders were not interviewed. In order to maximize the safety of research assistance, all observations and interviews were conducted during the daytime and lasted one and a half hours per study site per day for two weekdays and one weekend. Questions on the questionnaire were structured to gather data on riders’ sociodemographic characteristics, license holding and helmet ownership, observed helmet use and helmet types as well as reasons for wearing or not wearing a helmet among others. Questions also covered riders’ views about helmets features and knowledge of local helmet laws and
9
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ACCEPTED MANUSCRIPT helmet usefulness. A total of 20 statements (variables) with ‘yes’ or ‘no’ responses were used to measure riders knowledge, attitudes and beliefs towards helmets.
Data gathered were analysed using IBM SPSS version 20. Descriptive statistics on the study population as well as information on the frequency of helmet use were produced. Further
Downloaded by [University of Nebraska, Lincoln] at 15:11 07 April 2015
analysis was conducted using binary logistic regression to examine the association between the independent variables [socio-demographic variables, (see Table 1) and motorcyclists’ knowledge, attitudes and beliefs on helmet use (see Table 3)] and the dependent variable (helmet use). The independent variables were identified through literature from previous studies, informal conversations with motorcyclist and relevant stakeholders in road safety as well as through findings from an earlier observational study on helmet use by the authors. Odds ratios (ORs; with 95% confidence intervals [CIs] were used to assess the strength of association. Tests were defined as significant when the two-sided ‘p’ value was
Traffic Injury Prevention Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/gcpi20
Correlates and Barriers associated with Motorcycle Helmet use in Wa, Ghana a
a
a
Millicent Awialie Akaateba , Ibrahim Yakubu & Bernard AfiikAkanpabadai Akanbang a
Department of Planning and Management, FPLM, University for Development Studies Wa, Ghana Accepted author version posted online: 20 Mar 2015.
Click for updates To cite this article: Millicent Awialie Akaateba, Ibrahim Yakubu & Bernard AfiikAkanpabadai Akanbang (2015): Correlates and Barriers associated with Motorcycle Helmet use in Wa, Ghana, Traffic Injury Prevention, DOI: 10.1080/15389588.2015.1024833 To link to this article: http://dx.doi.org/10.1080/15389588.2015.1024833
Disclaimer: This is a version of an unedited manuscript that has been accepted for publication. As a service to authors and researchers we are providing this version of the accepted manuscript (AM). Copyediting, typesetting, and review of the resulting proof will be undertaken on this manuscript before final publication of the Version of Record (VoR). During production and pre-press, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal relate to this version also.
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
ACCEPTED MANUSCRIPT Correlates and Barriers associated with Motorcycle Helmet use in Wa, Ghana
Millicent Awialie AKAATEBA1, Ibrahim YAKUBU, Bernard AfiikAkanpabadai AKANBANG
Downloaded by [University of Nebraska, Lincoln] at 15:11 07 April 2015
Department of Planning and Management, FPLM, University for Development Studies Wa, Ghana
1
Corresponding author’s address: Department of Planning and Management, FPLM, University
for Development Studies, UPW 3, Wa, Ghana. Email Address: [email protected] / [email protected]
ABSTRACT Objective: This study was conducted to investigate the correlates and barriers to helmet use among motorcycle riders in Wa, a motorcycle predominant town in Ghana. An additional objective was to find out the association between helmet use and riders’ knowledge, attitudes and beliefs towards helmets. Methods: Cross-sectional surveys comprising both observation of helmet use and interviews were conducted among motorcycle riders at six randomly selected fuel stations and four
1
ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT motorcycle service centres within and outside the Central Business District of Wa. Questions covered riders’ socio-demographic and riding characteristics, helmet use, reasons for use or nonuse of helmets, and knowledge, attitudes and beliefs about helmets. Analyses were based on frequencies and testing of strength of association using adjusted odds ratios (with 95%
Downloaded by [University of Nebraska, Lincoln] at 15:11 07 April 2015
confidence intervals) in Binary Logistic Regression. Results: The prevalence of helmet use among the 271 sampled riders was 46% (95% CI: 40.252.0). Gender, age, marital status and occupation were significant socio-demographic correlates of helmet use in Wa. Compared to currently married riders, unmarried riders were 5times less likely to use a helmet. No significant association existed between riders’ educational attainment and helmet use. Helmet use was also positively correlated with helmet ownership and license holding. The leading reasons stated for helmet non-use among non-users were, not travelling on a long distance and helmets block vision and hearing. Protection from injury, legal requirement, and coping with the police for fear of being accosted for helmet non-use were identified as common reasons for helmet use. Positive attitudes and beliefs were also significantly correlated with helmet use. Conclusions: Despite the existence of a legislation mandating the use of helmets on all roads as well as the high level of awareness among riders on this legislation and the benefits of helmets, the incidence of helmet use among motorists continue to be low in Wa, Ghana. This means that efforts to identify strategies to increase helmet use need to continue. The evidence provided by this study suggests that stakeholders in road safety need to put in interventions to ensure a rigorous enforcement of the helmet use legislation and improvement in helmet design. These
2
ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT should be combined with the development of targeted educational programs with the aim of changing unfavorable attitudes and beliefs towards helmet use.
Downloaded by [University of Nebraska, Lincoln] at 15:11 07 April 2015
KEYWORDS: Motorcycle riders; attitudes; factors; helmet; legislation; Northern Ghana
INTRODUCTION Injuries and deaths resulting from road traffic crashes are a growing public health concern in many developing countries. The majority of these deaths and injuries occur among “vulnerable road users” – pedestrians, pedal cyclists, motorcyclists and other two-wheeler users (Peden et al. 2004). Whilst in developed countries, a great proportion of road traffic fatalities involve fourwheeled vehicles with motorcyclists comprising between 5% and 18% of road traffic injury deaths, in developing countries, motorized two-wheelers account for a significant proportion. Motorcyclists comprise up to a third of all road fatalities in the South-East Asia and Western Pacific Regions (Peden et al. 2004; WHO 2013). Due to their relatively low cost, convenience, and ability to manoeuvre on congested roads, in middle and low-income countries, motorcycles are increasingly becoming a popular mode of transport and a fast growing segment of vehicular traffic (WHO 2006). This has raised great concern about the safety features of the motorcycle and rider attitudes and behaviours in recent time. Motorcycles constitute the most risky form of motorized transport. They offer very little protection for riders and passengers. Studies have revealed that riders of motorized two- wheeled
3
ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT vehicles have higher risks of accidents, injuries and deaths compared to users of other modes of transport (Koornstra et al. 2003; Huang and Preston 2004; Dandona et al. 2006; Elliott et al. 2007; Janmohammadi et al. 2009). Koornstra et al. (2003) estimated that per 100 million-person travelling hours, 25 car-driver fatalities occur compared to 440 motorized two-wheeled vehicle rider fatalities. Injuries to the head-neck region are the most frequent injuries suffered by
Downloaded by [University of Nebraska, Lincoln] at 15:11 07 April 2015
motorcyclists and the primary cause of death and disability in motorcycle-related traffic accidents (Liu et al. 2008; WHO 2013). Head injuries contribute up to 75% of deaths among two-wheeled vehicle users in European countries and to as high as 88 percent in some developing countries (WHO 2013). Instinctively, wearing standard motorcycle helmets could reduce the number of such head injuries and resulting deaths. The effectiveness of safety helmets in preventing and reducing the severity of head injuries as well as deaths and cost resulting from motorcycle crashes have been extensively studied and documented in literature (see Rowland et al. 1996; Christian et al. 2003; Hundley et al. 2004; Keng 2005; Sauter et al. 2005; O’Connor 2005; Norvell and Cummings 2005; Liu et al. 2008; Houston and Richardson 2008; Moskal et al. 2008; NHTSA, 2008; Cui et al. 2009). From a meta-analysis, Liu et al. (2008) concluded that helmet use reduces the risk of head injury by around 69% and death by around 42%. Chiu et al. (2000) identified that riders without safety helmets were twice as likely to receive a head injury compared to helmeted riders. Another metaanalysis study by MacLeod et al. (2010) that combined findings from several independent studies also concluded that the use of motorcycle helmets decreases the overall death rate of motorcycle crashes, reduces the incidence of lethal head injury and decreases the severity of nonlethal head injury in motorcycle crashes among helmeted riders compared with non-helmeted riders. The
4
ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT existence of mandatory universal helmet laws have also been established to increase helmet wearing rates (Ichikawa et al. 2003; Servadei et al. 2003; Karkhaneh et al. 2006; Houston 2007), leading to a reduction in mortality and head injury in geographical areas with the law when compared with areas without it (MacLeod et al. 2010). Despite the established benefits of safety helmets, many studies have revealed that helmet use among motorcyclists is low in many low
Downloaded by [University of Nebraska, Lincoln] at 15:11 07 April 2015
and middle income countries such as Greece (Germeni et al. 2009), Vietnam (Hung et al. 2006), Brazil (Liberatti et al. 2003), Thailand (Pitaktong et al. 2004), Pakistan (Khan et al. 2008), India (Sreedharan et al. 2010), Nigeria (Oginni et al. 2007), Malaysia (Kulanthayan et al. 2000), China (Xuequn et al. 2011), Iran (Ali et al. 2011) and Ghana (Akaateba et al. 2014; Ackaar and Afukaar 2010). Besides the existence of national legislations mandating motorcycle helmet use, many other correlates or factors have been widely established in literature to be associated with helmet use. These include age and gender (Hurt et al. 1981; Ichikawa et al. 2003; Mangus et al. 2004; Nakahara et al. 2005; Hung et al. 2006; Li et al. 2008; Ackaar and Afukaar 2010; Xuequn et al. 2011; Papadakaki et al. 2013); educational attainment (Hurt et al. 1981; Khan et al. 2008; Hung et al. 2008; Ranney et al. 2010); motorcyclists’ position on the motorbike, the time of day, day of week and location or type of road travelled on (Skalkidou et al. 1999; Nakahara et al. 2005; Xuequn et al. 2011; Bachani et al. 2012; Akaateba et al. 2014). Other factors such as travel distance; (Ouellet, 2011; Kulanthayan et al. 2000; Hung et al. 2008); weather condition (Skalkidou et al. 1999; Ledesma and Peltzer 2008; Gkritza 2009; Ledesma et al. 2014); history of a motorcycle accident or injury (Mangus et al. 2004; Pitaktong et al. 2004; Ranney et al. 2010; Siviroj, 2012); possession of a rider’s license (Reeder et al.1997; Kulanthayan et al. 2000),
5
ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT embarrassment (Moghisi et al 2014a; 2014b) as well as helmet features and rider perceptions (Hung et al. 2008; Kennedy et al. 2011; Bogerd et al. 2011; Orsi et al. 2012) have been identified to be associated with helmet use. These studies have generally concluded that helmet non-use is significantly correlated with young riders, male riders, less educated riders, pillion riders, riding at night time, riding on weekends and on rural and secondary roads, travelling on short distances,
Downloaded by [University of Nebraska, Lincoln] at 15:11 07 April 2015
good weather conditions, previous involvement in motorcycle accident, unlicensed riders and negative perceptions of helmet features and their associated discomfort. Other studies have established that riders’ knowledge, beliefs and attitudes towards helmets have significant influence on helmet use. Knowledge and beliefs about helmet safety and injury prevention act as a catalyst for helmet use whilst motorcyclists negative attitudes and beliefs about helmet features such as limited vision and hearing, discomfort and cost of helmets act as major barriers to helmet use (WHO 2006; Hung et al. 2008; Khan et al. 2008, Li et al. 2008; Ranney et al. 2010; Bachani et al. 2012; Papadakaki et al. 2013). In Ghana, motorcycles are a common mode of transport, particularly in rural areas. However, in recent time, they are increasingly becoming popular in many cities as an economical alternative mode of transport in congested road networks. Between 2000 and 2010, motorcycles registered in Ghana increased by more than five times, from 6,440 registered motorcycles in 2000 to 36,097 vehicles in 2010. Between 2010 and 2012, registered motorcycles almost doubled to 60,262 (DVLA 2013). This increase in motorcycles was accompanied by a corresponding increase in motorcycle fatalities and injuries. In absolute terms, motorcycle fatalities increased lamentably by 430% between 2000 and 2010. Consequently, motorcyclists fatalities as a proportion of the total road fatalities recorded in the country increased from 2% in 2000 to 9% in 2010 and to 15%
6
ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT in 2012 (NRSC 2012). In the northern part of Ghana, motorcycles are the most common form of transport providing mobility to millions of people as well as goods. Almost every urban household anecdotally in Northern Ghana owns a motorcycle. As a result, motorcycle riding is one of the activities every young adult must learn to do. The dominance of the motorcycle in northern Ghana has made it the major cause of traffic-related morbidity and mortality in these
Downloaded by [University of Nebraska, Lincoln] at 15:11 07 April 2015
areas, thus constituting a major economic burden to the country (Kudebong et al. 2011). In the Wa Municipality where this study is situated, motorcycles represented 98% of the total registered vehicles in the Municipality in 2012 and accounted for 80% of road fatalities (NRSC 2012). Although Section 16 (1) of the Ghana Road Traffic Act, 2004 (ACT 683) mandates the wearing of motorcycle helmets by both riders and pillion riders, helmet use in Wa is low among motorcyclists (Akaateba et al. 2014). The dominance of the motorcycle as a mode of transport coupled with the low helmet use among riders and the resulting significant proportion of road traffic fatalities associated with motorcyclists in the Wa Municipality make a study into helmet use and its associated factors germane. The few existing scientific studies on helmet use in northern Ghana (Ackaar and Afukaar 2010; Akaateba et al. 2014) have largely focused on establishing the prevalence of helmet use among motorcyclists through observational surveys. However, besides determining the frequency of helmet use, there is the need to understand the factors associated with its use as well as motorcyclists prevailing knowledge, attitudes and beliefs around helmet use. This is particularly important so that appropriate and focused measures and interventions can be formulated and implemented to improve helmet use considering the daily accidents and serious injuries sustained by unhelmeted motorcyclists in the Wa Municipality. The aim of this paper
7
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ACCEPTED MANUSCRIPT therefore is to examine the correlates and barriers as well as motorcyclists’ knowledge, attitudes and beliefs associated with helmet use. This study is a follow up to an earlier study by Akaateba et al. (2014) on helmet use prevalence. It will add new evidence and information on helmet use in Wa and aid in policy formulation for motorcycle injury prevention in the country. The study is particularly relevant and opportune in the light of general calls from road safety activists for the
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National Road Safety Commission to develop effective interventions towards reducing the undesirable proportion of motorcycle fatalities and injuries in the Wa Township. The study generates useful evidence to assist in the development of evidence-based interventions tailored towards motorcycle helmet use.
METHODS The study adopted a cross sectional survey approach to obtain information from a random sample of motorcycle riders in Wa, Ghana. The data for this study were collected as part of a week-long study on helmet use in June 2013. Wa doubles as the capital of the Upper West Region (the youngest region in Ghana) and the Wa Municipality. It has a total population of 78,993 as per the 2010 Population and Housing Census and is a motorcycle-predominant town. Anecdotal evidence suggests that there exist at least one motorcycle in almost every home in the Wa Township.
The data collection approach for the study involved both observation of helmet use and interviews on helmet use barriers, knowledge, attitudes and practices. The study sites comprised of fuel stations and motorcycle service centers located along major routes leading to the Central
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ACCEPTED MANUSCRIPT Business District (CBD). These sites were first categorized into two: sites within the CBD of Wa (≤1km) and sites outside the CBD of Wa (>1km). Using a simple random sampling strategy, 6 fuel stations (3 from each category) were randomly selected from the 11 eligible fuel stations. Four motorcycle service centres comprising two within and two outside the CBD of Wa were
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also randomly selected.
At each fuel station or motorcycle service centre, trained research assistants approached at random motorcycle riders who had stopped to refuel or to service their motorcycles to explain the purpose of the survey to them and obtain their consent. Where a motorcycle rider consented to the survey (about 8 in 10 motorcyclists approached agreed to participate) the research assistants recorded the rider’s use or non-use of a helmet and proceeded to conduct a face-to-face interview using a semi-structured questionnaire that was piloted on 20 riders at two sites within and outside the CBD. The respondents were not aware of being observed as the research assistants did the observation of the safety helmet use from a distance before approaching them. The survey covered only motorcycle riders. Pillion riders were not interviewed. In order to maximize the safety of research assistance, all observations and interviews were conducted during the daytime and lasted one and a half hours per study site per day for two weekdays and one weekend. Questions on the questionnaire were structured to gather data on riders’ sociodemographic characteristics, license holding and helmet ownership, observed helmet use and helmet types as well as reasons for wearing or not wearing a helmet among others. Questions also covered riders’ views about helmets features and knowledge of local helmet laws and
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ACCEPTED MANUSCRIPT helmet usefulness. A total of 20 statements (variables) with ‘yes’ or ‘no’ responses were used to measure riders knowledge, attitudes and beliefs towards helmets.
Data gathered were analysed using IBM SPSS version 20. Descriptive statistics on the study population as well as information on the frequency of helmet use were produced. Further
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analysis was conducted using binary logistic regression to examine the association between the independent variables [socio-demographic variables, (see Table 1) and motorcyclists’ knowledge, attitudes and beliefs on helmet use (see Table 3)] and the dependent variable (helmet use). The independent variables were identified through literature from previous studies, informal conversations with motorcyclist and relevant stakeholders in road safety as well as through findings from an earlier observational study on helmet use by the authors. Odds ratios (ORs; with 95% confidence intervals [CIs] were used to assess the strength of association. Tests were defined as significant when the two-sided ‘p’ value was
