The frequency and predictors of helmet use among Iranian motorcyclists: A quantitative and qualitative study

Objective

This study examines the rate of helmet use and identifies barriers and facilitators of wearing helmets among Iranian motorcyclists. A mixed-method approach was used, including a structured seasonal survey with specific observations of a random sample of 6010 riders and qualitative methods that included 29 in-depth interviews and seven focus groups (n = 31).

Results

Only 10% of motorcyclists wear a standard helmet while riding. However, another 23% of motorcyclists used non-standard or partial helmets that covered only part of the head and do not prevent head trauma injuries effectively. We observed only 2 of 264 child passengers and 22 of 1951 adult passengers wearing helmets. Almost no one used protective pants or clothing made to be more visible in traffic. Themes emerged from qualitative interviews and were grouped into three main categories: (1) helmet characteristics; (2) social and cultural factors; and (3) personal and psychological factors.

Conclusion

Overall, the motorcyclists in our study believed that wearing a safety helmet protects them against serious injuries or death during a crash; however, only a small percentage of the motorcyclists used safety helmets. National intervention programs addressing motorcycle safety should aim to overcome barriers to and promote facilitators of helmet use, including providing inexpensive standard helmets, banning manufacturing/using unsafe partial or dummy helmets, as well as enforcing helmet use on a consistent basis.     

Barriers to, and factors associated, with observed motorcycle helmet use in Vietnam

This study investigated barriers to, and factors associated with, observed motorcycle helmet use among motorcyclists in Hai Duong Province, Vietnam. The findings highlighted an array of factors associated with observed helmet use namely, support for universal helmet legislation and a positive attitude towards what might be perceived as negative attributes of helmet use such as inconvenience and discomfort in hot weather. As well, older age (greater than 25 years in age), riding on a compulsory road, being a driver, trips of greater than 10 km, higher levels of education (having a university degree and higher) were found to be key determinants of helmet use. Despite over 95% of motorcyclists disagreeing with the statement that wearing a helmet does not reduce the severity of head injury in a crash, most motorcyclists believed that helmets did not need to be worn for a short trip. Overall, only 23% of motorcyclists were observed wearing a helmet. The authors conclude that efforts to increase helmet use need to focus on the necessity for universal helmet legislation in association with identifying solutions to reduce the negative attitudes towards helmet use.     

Correlates of motorcycle helmet use among recent graduates of a motorcycle training course

Helmets significantly decrease morbidity and mortality from motorcycle crashes, but many areas of the world lack universal helmet laws. To educate motorcyclists in areas without helmet laws, more knowledge of motorcyclists’ helmet beliefs is needed.A web-based survey was therefore designed to assess motorcyclists’ attitudes, norms and behaviors towards helmets in a U.S. state with a limited helmet law. Of 445 survey respondents, 68.4% of respondents reported always wearing a helmet. The not-always-helmeted riders were more likely than the always-helmeted to be male; to bave less education; and to have a history of previous motorcycle crashes and injuries. Although both groups had taken rider training classes, fewer of the not-always-helmeted had learned how to ride in a class. The strongest correlates of being not-always-helmeted (vs. always-helmeted) were attitudes that helmets were not protective and impaired sight/hearing; and the normative belief that they would only wear helmets if forced by law. Because attitudes are often more easily changed than normative beliefs, education may increase helmet use. However, less than half of riders in this state with a mandatory education program learned how to ride from a rider education course, and 44% of non-helmeted said they would only wear a helmet if forced by law. Legislation may therefore be a more efficient and effective strategy than education to increase helmet use.     

Helmet use and motorcycle fatalities in Taiwan

Motorcycle deaths accounted for more than half of total traffic fatalities in Taiwan in 2002. This study uses the police-reported crash data from Taiwan between 1999 and 2001 to estimate the effectiveness of helmets, simultaneously taking into account of sample selection bias. Sample selection arises because helmet usage will affect the probability of death or injury, which in turn influences whether a crash is included in the data. The results show that sample selection does not seriously bias the estimate of helmet effectiveness and helmets reduce the probability of death in a crash by 40%, which is higher than what was previously found. Without helmets, the number of motorcyclists killed in 2001 would have jumped by 51%. The estimated proportion of helmeted motorcyclists has increased from 71 to 78% between 1999 and 2001, suggesting that helmet use is rising after the implementation of mandatory helmet law in 1997. Also, helmets significantly reduce the likelihood of head and neck injuries in a crash by 53%, and lead to a 71% reduction in the probability of death caused by head and neck injuries.     

Improper motorcycle helmet use in provincial areas of a developing country

Motorcycle helmet wearing rates remain low in smaller cities in developing countries. We therefore examined the knowledge, attitudes, and behavior of motorcyclists towards helmet use in two mid-sized cities in China. The methods included roadside observation and interview. Observational sites were randomly selected from main roads and secondary streets; all motorcycles passing by were observed. Riders near the sites were opportunistically approached and asked about knowledge of and perceptions about helmet use. Altogether, 75,949 drivers and 17,230 passengers were observed. A large proportion of both drivers and passengers (34% and 71%, respectively) did not wear a helmet, or did not have their helmet fastened (34% and 14%). Proper helmet usage rates were lower among male drivers, younger people, on secondary streets, and during the evenings and weekends. The majority of the 2325 drivers interviewed (90%) acknowledged the benefits of helmet wearing, but 72% reported that helmets are not always comfortable, and only 20% said they would wear a helmet for preventive purposes. Furthermore, many felt that police enforcement was not strict (62%). These results suggest that educational programs about helmet use in provincial China should emphasize the risks of improper use. Strict enforcement, especially on secondary roads and during non-peak hours, could also improve helmet usage.     

The prevalence of non-standard helmet use and head injuries among motorcycle riders

OBJECTIVES: This study examined the prevalence of non-standard helmet use among motorcycle riders following introduction of a mandatory helmet use law and the prevalence of head injuries among a sample of non-standard helmet users involved in motorcycle crashes. METHODS: Motorcycle rider observations were conducted at 29 statewide locations in the 2 years following the introduction of the mandatory helmet use law in January, 1992. Medical records of motorcyclists who were injured in 1992 for whom a crash report was available and for whom medical care was administered in one of 28 hospitals were reviewed. Chi-squares and analysis of variance were used to describe differences between groups. RESULTS: Prevalence of non-standard helmet use averaged 10.2%, with a range across observation sites from 0 to 48.0%. Non-standard helmet use varied by type of roadway, day of week, and time of day. Injuries to the head were more frequent and of greater severity among those wearing non-standard helmets than both those wearing no helmet and those wearing standard helmets. CONCLUSIONS: Non-standard helmets appear to offer little head protection during a crash. Future study is needed to understand the dynamics leading to head injury when different types of helmets are worn.     

Characteristics of motorcycle-related hospitalizations: comparing states with different helmet laws

This study compares U.S. motorcycle-related hospitalizations across states with differing helmet laws. Cross-sectional analyses of hospital discharge data from 33 states participating in the Healthcare Cost and Utilization Project in 2001 were conducted. Results revealed that motorcyclists hospitalized from states without universal helmet laws are more likely to die during the hospitalization, sustain severe traumatic brain injury, be discharged to long-term care facilities, and lack private health insurance. This study further illustrates and substantiates the increased burden of hospitalization and long-term care seen in states that lack universal motorcycle helmet use laws.     

A cross-sectional observational study of helmet use among motorcyclists in Wa,Ghana

Motorcyclists’ injuries and fatalities are a major public health concern in many developing countries including Ghana. This study therefore aimed to investigate the prevalence of helmet use among motorcyclists in Wa, Ghana. The method used involved a cross-sectional roadside observation at 12 randomly selected sites within and outside the CBD of Wa. A total of 14,467 motorcyclists made up of 11,360 riders and 3107 pillion riders were observed during the study period. Most observed riders (86.5%) and pillion riders (61.7%) were males. The overall prevalence of helmet use among the observed motorcyclists was 36.9% (95% CI: 36.1–37.7). Helmet use for riders was 45.8% (95% CI: 44.8–46.7) whilst that for pillion riders was 3.7% (95 CI: 3.0–4.4). Based on logistic regression analysis, higher helmet wearing rates were found to be significantly associated with female gender, weekdays, morning periods and at locations within the CBD. Riders at locations outside the CBD were about 7 times less likely to wear a helmet than riders within the CBD (48.9% compared to 42.3%; χ²₍₁₎ = 49.526; p < 0.001). The study concluded that despite the existence of a national helmet legislation that mandates the use of helmets by both riders and pillion riders on all roads in Ghana, helmet use is generally low in Wa. This suggests that all stakeholders in road safety should jointly intensify education on helmet use and pursue rigorous enforcement on all road types especially at locations outside the CBD to improve helmet use in Wa.     

Motorcyclist fatalities and the repeal of mandatory helmet wearing laws

Previous studies had estimated that repeal of mandatory helmet wearing laws resulted in increases in the number of fatalities ranging from nearly 40% to essentially zero. This study was performed to determine more definitively the influence on motorcyclist fatalities of these repeals. After repeal, motorcyclist fatalities increased more in the states which repealed their laws than in those which did not in 24 cases out of 26, with the 95% confidence interval for the average effect being 25 +/- 6%. It is therefore concluded that repeals of mandatory helmet wearing laws for motorcyclists were followed by substantial increases in motorcyclist fatalities.     

Effect of the helmet act for motorcyclists in Thailand

OBJECTIVES: This study investigated the effect of the helmet act for motorcyclists on increasing helmet use and reducing motorcycle-related deaths and severe injuries in Thailand. METHODS: Data were derived from a trauma registry at the Khon Kaen Regional Hospital in the northeast Thailand. Helmet use and outcome in motorcycle crashes were compared 2 years before (1994-1995) and after (1996-1997) enforcement of the helmet act. During the study period, there were 12002 injured motorcyclists including 129 death cases in the municipality of Khon Kaen Province who were brought to the regional hospital. RESULTS: After enforcement of the helmet act, helmet-wearers increased five-fold while head injuries decreased by 41.4% and deaths by 20.8%. Those who had head or neck injuries or died were less likely wearing a helmet. Compliance of helmet use was lower at night. Fatality of injured motorcyclists did not significantly decrease in the post-act period and among helmet-wearers. CONCLUSION: Enforcement of the helmet act increased helmet-wearers among motorcyclists but helmet use did not significantly reduce deaths among injured motorcyclists. Motorcyclists should be instructed to properly and consistently wear a helmet for their safety.     

Parental attitudes and behaviours concerning helmet use in childhood activities: Rural focus group interviews

Previous research demonstrates the importance of parents in ensuring that their children practice proper helmet use. Parents encourage helmet use by setting an example when they wear helmets, as well as establishing rules that the children are expected to follow. Research in the area of helmet use predominantly focuses on bicycle helmets, but there are a number of childhood activities for which a helmet is required. The purpose of this research was to examine rural parents’ attitudes toward helmet use and investigate when, and for what activities, they require their children to wear helmets. Rural parents were selected as there is evidence that helmet use is less frequent among children in rural settings.     

Evolution of bicycle helmet use and its determinants in France: 2000–2010

This paper aims to analyse helmet use in France, as a voluntary behaviour rather than a legal requirement, promoted by public awareness campaigns. It aims to investigate the determinants of helmet wearing and to explore its evolution from 2000 to 2010. The analysis relies on data from a series of general population surveys called “Health Barometers”: 2000 (n = 13,163), 2005 (n = 25,651) and 2010 (n = 8573). Multivariate logistic regressions were used to identify factors associated with helmet use and time trends. Nearly half of the 15–75 year olds surveyed reported that they rode a bicycle, and among these cyclists, 22.0% reported that they wore a helmet on their last ride. Further analysis by gender reveals that twice as many men than women wore helmets. Over the last decade, helmet use among cyclists has clearly increased, from 7.3% in 2000 to 22.0% in 2010, whereas the influence of social and economic factors, such as unemployment and wage disparities, appears to have decreased. Several determinants of bicycle helmet use were highlighted. To improve the effectiveness of further public information campaigns on helmet use, the key target groups should include women, under 25 year olds and people living in urban areas. Promoting the wearing of helmets among families should also be enhanced, given the higher rate of helmet use by parents as well as children.     

Motorcycle helmet use and the risk of head,neck, and fatal injury: Revisiting the Hurt Study

Most studies find strong evidence that motorcycle helmets protect against injury, but a small number of controversial studies have reported a positive association between helmet use and neck injury. The most commonly cited paper is that of Goldstein (1986). Goldstein obtained and reanalyzed data from the Hurt Study, a prospective, on-scene investigation of 900 motorcycle collisions in the city of Los Angeles. The Goldstein results have been adopted by the anti-helmet community to justify resistance to compulsory motorcycle helmet use on the grounds that helmets may cause neck injuries due to their mass. In the current study, we replicated Goldstein’s models to understand how he obtained his unexpected results, and we then applied modern statistical methods to estimate the association of motorcycle helmet use with head injury, fatal injury, and neck injury among collision-involved motorcyclists. We found Goldstein’s analysis to be critically flawed due to improper data imputation, modeling of extremely sparse data, and misinterpretation of model coefficients. Our new analysis showed that motorcycle helmets were associated with markedly lower risk of head injury (RR 0.40, 95% CI 0.31–0.52) and fatal injury (RR 0.44, 95% CI 0.26–0.74) and with moderately lower but statistically significant risk of neck injury (RR 0.63, 95% CI 0.40–0.99), after controlling for multiple potential confounders.     

Motorcycle helmet type and the risk of head injury and neck injury during motorcycle collisions in California

The use of novelty motorcycle helmets is often prompted by beliefs that wearing a standard helmet can contribute to neck injury during traffic collisions. The goal of this analysis was to examine the association between helmet type and neck injury risk and the association between helmet type and head injury. Data were collected during the investigation of motorcycle collisions of any injury severity by the California Highway Patrol (CHP) and 83 local law enforcement agencies in California between June 2012 and July 2013. We estimated head injury and neck injury risk ratios from data on 7051 collision-involved motorcyclists using log-binomial regression. Helmet type was strongly associated with head injury occurrence but was not associated with the occurrence of neck injury. Rider age, rider alcohol use, and motorcycle speed were strong, positive predictors of both head and neck injury. Interventions to improve motorcycle helmet choice and to counteract misplaced concerns surrounding neck injury risk are likely to lead to reductions in head injury, brain injury, and death.     

Bicycle helmet legislation: can we reach a consensus?

Debate continues over bicycle helmet laws. Proponents argue that case-control studies of voluntary wearing show helmets reduce head injuries. Opponents argue, even when legislation substantially increased percent helmet wearing, there was no obvious response in percentages of cyclist hospital admissions with head injury-trends for cyclists were virtually identical to those of other road users. Moreover, enforced laws discourage cycling, increasing the costs to society of obesity and lack of exercise and reducing overall safety of cycling through reduced safety in numbers. Countries with low helmet wearing have more cyclists and lower fatality rates per kilometre. Cost-benefit analyses are a useful tool to determine if interventions are worthwhile. The two published cost-benefit analyses of helmet law data found that the cost of buying helmets to satisfy legislation probably exceeded any savings in reduced head injuries. Analyses of other road safety measures, e.g. reducing speeding and drink-driving or treating accident blackspots, often show that benefits are significantly greater than costs. Assuming all parties agree that helmet laws should not be implemented unless benefits exceed costs, agreement is needed on how to derive monetary values for the consequences of helmet laws, including changes in injury rates, cycle-use and enjoyment of cycling. Suggestions are made concerning the data and methodology needed to help clarify the issue, e.g. relating pre- and post-law surveys of cycle use to numbers with head and other injuries and ensuring that trends are not confused with effects of increased helmet wearing.     

Bicycle helmet efficacy: a meta-analysis

Bicycle helmet efficacy was quantified using a formal meta-analytic approach based on peer-reviewed studies. Only those studies with individual injury and helmet use data were included. Based on studies from several countries published in the period 1987-1998, the summary odds ratio estimate for efficacy is 0.40 (95% confidence interval 0.29, 0.55) for head injury, 0.42 (0.26, 0.67) for brain injury, 0.53 (0.39, 0.73) for facial injury and 0.27 (0.10, 0.71) for fatal injury. This indicates a statistically significant protective effect of helmets. Three studies provided neck injury results that were unfavourable to helmets with a summary estimate of 1.36 (1.00, 1.86), but this result may not be applicable to the lighter helmets currently in use. In conclusion, the evidence is clear that bicycle helmets prevent serious injury and even death. Despite this, the use of helmets is sub-optimal. Helmet use for all riders should be further encouraged to the extent that it is uniformly accepted and analogous to the use of seat belts by motor vehicle occupants.     

Discrepancy in bicycle helmet use among college students between two bicycle use purposes: Commuting and recreation

Objectives

The purpose of the study was to examine associations between bicycle helmet use and attitudes among U.S. college students. Bicycle helmet use was assessed for two different bicycle use purposes: commuting to school and recreation.

Materials and methods

Student bicycle riders were recruited on the campus of a large public university in Colorado. Questionnaire development was guided by the Theory of Reasoned Action and Health Belief Model. Bicycle use and helmet use for the two purposes, attitudes toward helmet use and bicycle helmet regulations on campus, perceived risk of bicycle-related injury, subjective norms were asked. Bicycle helmet use was defined by current behaviors and intentions for the future, based on the Stages of Change model.

Results

A total of 192 questionnaires collected from students who rode bicycles for both commuting and recreation was used for the analysis. Bicycle helmet use differed depending on purposes of bicycle riding: 9.4% of bicycle riders wore bicycle helmets every time for commuting, while 36.5% did so for recreation. Different variables were associated with bicycle helmet use for commuting and recreation in logistic regression models, suggesting that psychosocial structures behind bicycle helmet use behaviors might differ between two bicycle use purposes, commuting and recreation.     

The protective performance of bicyclists' helmets in accidents

A study of the injuries sustained by 1,892 bicycle riders during accidents indicated that 432 of the bicyclists had been wearing a helmet and 64 of the latter group had sustained an impact to the helmet. The 64 helmets were evaluated in this project to relate the nature and severity of the impact they had sustained to the head injury experienced by the wearer. The protective performance of the helmet shells, impact absorbing liners, and retention systems were evaluated, and the severity of the impacts sustained by the helmets was simulated in the test laboratory. The simulation was performed by dropping sample helmets from progressively greater heights in a test apparatus until the damage observed on a sample helmet matched that observed on an accident damaged helmet. The severity observed in the simulated impacts was compared with the severity of test impacts prescribed in established helmet performance standards (ANSI 1984; Snell 1984; AS 1986). It was found that all of the impacts occurred against flat objects; a high proportion of helmets sustained more than one impact; most impacts occurred on areas of a helmet which were not tested during certification to a standard; and many impacts were more severe than those stipulated in performance standards. The predominant form of head injury recorded was low severity concussion--AIS-1, AIS-2, AIS-3. All serious head injuries occurred when the helmet came off the rider's head and collapsed due to a material defect or was struck predominantly below the rim. A high proportion of helmets worn by young riders had been misused, and many helmets displayed defects in the impact-absorbing liners. Recommendations have been made for improving helmet construction and altering current standards to reflect the conditions encountered in the field.     

Analysis of impact-induced damage and delamination in the composite shell of a helmet

The impact energy absorption by helmets is of vital importance to the safety of motorcyclists during accidents. The paper is concerned with the study of damage and delamination, which are the principal modes of failure and energy absorption, in a composite shell and their influence on the impact performance of a helmet. Numerical simulations were conducted with different composite shells made of cross-ply laminate, woven fabric, and glass mat. The effectiveness of the numerical model is established using available experimental results from the literature. Hashin failure criteria and cohesive zone model (CZM) were used for predicting the in-plane damage and delamination in composite plies, respectively. An interface layer having a bilinear relationship between traction and relative displacement was placed between the plies of the composite shell to predict the delamination. The influence of damage and delamination in shells made of composite materials on impact-induced forces is evaluated and their performance is compared with helmet shells made of Acrylonitrile Butadiene Styrene (ABS).