539544 research-article2014
APHXXX10.1177/1010539514539544Asia-Pacific Journal of Public HealthWaseela and Laosee
Article
Determinants of Road Traffic Injury Among Adult Motorcyclists in Malé, Maldives
Asia-Pacific Journal of Public Health 2015, Vol. 27(3) 277–285 © 2014 APJPH Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1010539514539544 aph.sagepub.com
Mariyam Waseela, MPHM, and Orapin Laosee, PhD
Abstract This study investigates the incidence of nonfatal road traffic injuries (RTIs) in Malé, the capital city of the Maldives, and identifies risk factors associated with RTIs. A cross-sectional descriptive study was conducted among young adult motorcyclists in 3 public areas. A total of 350 selfadministered questionnaires were distributed to the motorcycle riders who visited the study areas between December 2012 and January 2013. The incidence of RTIs for the previous 12 months was 39.8% among the 294 respondents who returned a completed questionnaire. About half (49.6%) of those were caused by the riders. The majority of riders were male (96.6%). None of the motorcycle riders wore a helmet. RTIs had a significant association with sex, age, and attitude. Young riders were 1.6 times more likely to be involved in an RTI (adjusted odds ratio [AOR] = 1.67; 95% confidence interval [CI] = 0.94-2.95). Having a negative attitude about road safety was a risk factor of RTIs (AOR = 1.84; 95% CI = 1.11-3.03). Based on the results of the present study, it is important to promote safe riding attitudes in young riders. Keywords traffic injury, risk factors, injury prevention, motorcyclists, Maldives
Introduction Road traffic injuries (RTIs), including motorcycle-related injuries, are a global health problem. According to the World Health Organization, an estimated 1.2 million people die in road traffic accidents each year and as many as 50 million are injured.1 It has been estimated that by 2020, RTIs will be the third most important global cause of disease or injury if proper preventive action is not taken. Furthermore, 90% of global road fatalities occur in low- and middle-income countries, which have only 48% of the world’s registered vehicles.2 It has been estimated that RTIs cost between 1% and 2% of the national product and more than US$100 billion a year in those countries.1 The Maldives, with a total of more than 1000 islands, is one of the most popular tourist destinations in the world. It has one of the fastest-growing rates for motor vehicles in South Asia. Malé, the capital city of the Maldives, is considered to have one of the highest concentrations of
ASEAN Institute for Health Development, Mahidol University, Nakhonpathom, Thailand Corresponding Author: Orapin Laosee, ASEAN Institute for Health Development, Mahidol University, Salaya, Phutthamonthon, Nakhonpathom 73710, Thailand. Email: [email protected]
Downloaded from aph.sagepub.com at UNIVERSITE DE MONTREAL on September 2, 2015
278
Asia-Pacific Journal of Public Health 27(3)
population, more than 100 000 people living in an area of 2.5 km2. Because of the small size of the city, motorcycles have become a popular means of transportation as they are relatively affordable to buy and operate. In 2011, a total of 50 052 motor vehicles were registered, and approximately 80% were motorized 2- and 3-wheeled vehicles.1 Riders of such vehicles are at an increased risk of collision because the small size of the motorcycle makes them less visible to automobile drivers.3 Previous studies have shown that the human error is the most common risk factor, accounting for more than 85% of all traffic accidents.1,2,4,5 Among risky types of behavior, 3 kinds of driving behavior can increase the risks of motor vehicle crashes: running red lights, exceeding the posted speed limit, and aggressive driving.4,6 Adults aged between 15 and 44 years are considered as a vulnerable group, accounting for 59% of traffic deaths. More than three quarters (77%) of all traffic deaths occur among men.1 According to reports by the Maldivian police services, road traffic accidents have been increasing dramatically.7 Because of inadequacies in reports regarding injuries and lack of data collection system, the actual picture is not accurately reflected in the available statistics. Therefore, the aim of this study was to ascertain the incidence of and determine the risk factors for nonfatal RTIs among young adult riders in the capital city of the Maldives. The study helps provide evidence-based information about the situation regarding RTIs in the city, which could be useful to policy makers in making decisions about developing road safety strategies.
Methods This cross-sectional study was conducted during December 2012 to January 2013. Motorcyclists who were residents of Malé, aged between 18 and 44 years, and agreed to participate were recruited for this study. Ethical clearance was obtained from the Committee for Research Ethics (Social Sciences), Mahidol University, and the National Health Research Committee, Ministry of Health and Family, the Maldives. Written consent was obtained from each respondent. The sample size was calculated using a confidence interval (CI) of 95%, an acceptance error of 6%, and estimate proportion of having RTIs of 0.5. Cluster stage sampling was used to identify the study sites. Of 10 public places (markets, parks, piers) in Malé, 3 were randomly selected as sites for interviews. Trained research assistants approached every 10th motorcycle rider who entered the study sites from 9:00 am to 4:00 pm Sunday to Thursday (weekday) and from 10:00 am to 5:00 pm Friday and Saturday (weekend). On average, each respondent took 10-15 minutes to complete the questionnaire. A self-administered questionnaire was developed based on a review of the literature.8-15 The questionnaire was designed to gather the following information: (a) sociodemographic characteristics—gender, age, education, income, and occupation and (b) knowledge, attitude, and behavior related to road safety. In the section about knowledge, 15 questions were asked about safety information regarding riding motorcycles, such as using a helmet and risky driving. The total score for the knowledge part was classified into 2 categories: “good” if the score was more than 75% or >9, whereas “poor” was given to scores of equal or less than 75% or ≤9. The attitude section discussed attitudes concerning safety issues, such as wearing helmets, speeding, traffic regulations, and using handheld phones while riding a motorcycle. Scoring for each statement was 5, 4, 3, 2, and 1, corresponding to strongly agree, agree, not sure, disagree, and strongly disagree, respectively. The score was reversed for negative statements and scores ranged from 12 to 60. Total score was classified into 1 of 2 groups: “positive attitude” (more than the mean; score 42-55) and “negative attitude” (equal to or less than the mean; score 25-41). The behavior section addressed safe practices when riding, such as wearing helmets, speeding, using mobile phones, and running red lights. For this part, scoring was as follows: 5 = always, 4 = very often, 3 = sometimes, 2 = occasionally, 1 = never. Scoring was reversed for
Downloaded from aph.sagepub.com at UNIVERSITE DE MONTREAL on September 2, 2015
279
Waseela and Laosee
negative statements. The total possible score ranged from 10 to 50. Total scores were divided into 2 categories: a total score more than the mean (37-41) was considered “safe riding”; a score of less than or equal to the mean (26-36) was classified as “risky riding.” The final part of the questionnaire asked about experience of nonfatal RTIs in the 12 months prior to interview and the primary cause of injuries. The questionnaire was tested for reliability among 30 motorcyclists. The Kuder-Richardson (KR-20) test score for the knowledge section was 0.46, while Cronbach’s alphas for attitude and behavior were .69 and .70, respectively. The questionnaire was translated from English to Dhivehi, the national language. Checking the translation was done with the help of 2 local teachers to ensure that the translated questionnaire was equivalent to its English original. Univariate analysis was performed to describe the mean, standard deviation (for normal distribution variables), median, quartile deviation (for nonnormal distribution variables), minimum, maximum, number, and percentage. χ2 tests were used to determine a possible association between RTIs and each independent variable. The magnitude of association is described by odds ratio (OR) with 95% CI. Finally, a multiple logistic regression was calculated to identify the association between independent variables and risk of RTIs. To avoid distortion of the model, only males who were the majority of riders (96.6%) were included in the multiple logistic regression. A P value 10 000 ≤10 000 Occupation Private sector employee Other Years in possession of a license 1-6 7-20 Usual average speeda Excessive speed Average
Yes (%)
No (%)
Crude OR (95% CI)
P value
284 10
40.8 10.0
59.2 90.0
6.21 (0.77-49.77) 1
.08
68 226
50.0 36.7
50.0 63.3
1.72 (0.99-2.98) 1
.05
235 59
38.7 44.1
61.3 55.9
1.25 (0.70-2.22) 1
.45
178 116
40.4 38.8
59.6 61.2
1.07 (0.66-1.79) 1
.78
158 136
41.1 38.1
58.9 61.9
1.12 (0.71-1.81) 1
.61
114 178
43.0 37.1
57.0 62.9
1.27 (0.79-2.06) 1
.31
159 135
44.0 34.8
56.0 65.2
1.44 (0.92-2.36) 1
.10 (continued)
Downloaded from aph.sagepub.com at UNIVERSITE DE MONTREAL on September 2, 2015
282
Asia-Pacific Journal of Public Health 27(3)
Table 3. (continued) Traffic Injury in the Previous 12 Months Variables
n
Knowledge Good Poor Attitude Negative Positive Behavior Risky Safe
Yes (%)
No (%)
Crude OR (95% CI)
P value
71 223
45.1 38.1
54.9 61.9
1.33 (0.77-2.28) 1
.29
168 126
46.4 31.0
53.6 69.0
1.93 (1.19-3.14) 1
20 km/h) Poor level of knowledge Negative attitude toward road safety Risky riding behavior
Adjusted OR (95% CI)
P value
1.67 (0.94-2.95) 1.37 (0.84-2.24) 0.79 (0.45-1.39) 1.84 (1.11-3.03) 1.38 (0.83-2.29)
.08 .21 .42 .02 .21
Abbreviations: OR, odds ratio; CI, confidence interval.
This study indicates that young riders are 1.7 times more likely to be involved in an RTI than those older than 25 years. This finding is similar to those of studies done previously. Several studies have demonstrated that young drivers are more frequently involved in risky behavior and traffic accidents than other age-groups.6,17,18 In addition, attitude also plays a crucial role in safe riding. Our study shows that those who have a negative attitude are more likely to have RTIs. Knowledge of safe driving practices was not associated with injuries. This evidence suggests that conducting interventions to promote safety concern and focusing traffic rules among young males could be considered as the initial strategies in Malé. This study found that the primary causes of traffic injuries were a result of human factors. Deliberate traffic violations are one of the most common causes of injuries. For instance, excessive speed and violating other traffic rules were frequently cited by those who had had RTIs. The findings of our study are similar to those of a study in Taiwan that found that traffic violations increase the risk of accidents.6 However, in the capital city of Malé, the law sets the speed limit as low as 20 km/h. If riders travel at such a reduced speed, they will feel that it would take them too long to reach their destination. In this study, high number of traffic injuries were caused by excessive speed. Therefore, excessive speed in this study is not referred to as unsafe riding, like in many other countries, but as a distinct risk factor. A study of 3-wheeler taxi drivers in Sri Lanka revealed that more than half (52.9%) were categorized as aggressive driving, whereas 41% had experienced running a red light.19 Previous studies have identified various strategies against excessive speed and red light violations, such as law enforcement, penalties, and behavioral interventions.20-23 A study in Hong Kong indicated that the frequency of red light violations
Downloaded from aph.sagepub.com at UNIVERSITE DE MONTREAL on September 2, 2015
283
Waseela and Laosee
on the part of drivers significantly decreased after the introduction of demerit points and financial penalties.20 This evidence would be useful in developing a road safety strategy for Malé. Since there is no existing legislation regarding helmet use in Malé, our study is the first one that highlights the fact that none of the motorcycle riders wore helmets, even though they knew the benefits of wearing one. Other research shows that wearing a helmet reduces the risk of death in motorcycle crashes.24-27 Enforcement of the helmet act is the key to increasing the rate of helmet use.28 A study in Thailand has shown that after enforcement of the helmet act, helmet wearers increased 5-fold while head injuries decreased by 41%. Mortality decreased by 20.8%.27 Hyder et al29 concluded that enforced, mandatory motorcycle helmet laws are potentially one of the most cost-effective interventions available for low- and middle-income countries with high rates of motorcycle injuries. According to the report of global status on road safety 2013, 90 countries (77% of the world’s population) have a comprehensive helmet law, covering all riders, all roads, and all engine types. They also apply helmet manufacturing standards. In Cambodia, a law requiring motorcycle drivers to wear a helmet was passed in 2009. After the law’s adoption, approximately 60% of the drivers wear helmets. In 2010, the Cambodian government embarked on a program to increase helmet wearing through enhanced enforcement and legislation. The program includes building police capacity to enforce the law, implementing helmet check points, and revising legislation to increase penalties for noncompliance.1 The government is still working with other national partners to extend the existing helmet law to include passengers. However, passenger helmet user rates are very low (
APHXXX10.1177/1010539514539544Asia-Pacific Journal of Public HealthWaseela and Laosee
Article
Determinants of Road Traffic Injury Among Adult Motorcyclists in Malé, Maldives
Asia-Pacific Journal of Public Health 2015, Vol. 27(3) 277–285 © 2014 APJPH Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1010539514539544 aph.sagepub.com
Mariyam Waseela, MPHM, and Orapin Laosee, PhD
Abstract This study investigates the incidence of nonfatal road traffic injuries (RTIs) in Malé, the capital city of the Maldives, and identifies risk factors associated with RTIs. A cross-sectional descriptive study was conducted among young adult motorcyclists in 3 public areas. A total of 350 selfadministered questionnaires were distributed to the motorcycle riders who visited the study areas between December 2012 and January 2013. The incidence of RTIs for the previous 12 months was 39.8% among the 294 respondents who returned a completed questionnaire. About half (49.6%) of those were caused by the riders. The majority of riders were male (96.6%). None of the motorcycle riders wore a helmet. RTIs had a significant association with sex, age, and attitude. Young riders were 1.6 times more likely to be involved in an RTI (adjusted odds ratio [AOR] = 1.67; 95% confidence interval [CI] = 0.94-2.95). Having a negative attitude about road safety was a risk factor of RTIs (AOR = 1.84; 95% CI = 1.11-3.03). Based on the results of the present study, it is important to promote safe riding attitudes in young riders. Keywords traffic injury, risk factors, injury prevention, motorcyclists, Maldives
Introduction Road traffic injuries (RTIs), including motorcycle-related injuries, are a global health problem. According to the World Health Organization, an estimated 1.2 million people die in road traffic accidents each year and as many as 50 million are injured.1 It has been estimated that by 2020, RTIs will be the third most important global cause of disease or injury if proper preventive action is not taken. Furthermore, 90% of global road fatalities occur in low- and middle-income countries, which have only 48% of the world’s registered vehicles.2 It has been estimated that RTIs cost between 1% and 2% of the national product and more than US$100 billion a year in those countries.1 The Maldives, with a total of more than 1000 islands, is one of the most popular tourist destinations in the world. It has one of the fastest-growing rates for motor vehicles in South Asia. Malé, the capital city of the Maldives, is considered to have one of the highest concentrations of
ASEAN Institute for Health Development, Mahidol University, Nakhonpathom, Thailand Corresponding Author: Orapin Laosee, ASEAN Institute for Health Development, Mahidol University, Salaya, Phutthamonthon, Nakhonpathom 73710, Thailand. Email: [email protected]
Downloaded from aph.sagepub.com at UNIVERSITE DE MONTREAL on September 2, 2015
278
Asia-Pacific Journal of Public Health 27(3)
population, more than 100 000 people living in an area of 2.5 km2. Because of the small size of the city, motorcycles have become a popular means of transportation as they are relatively affordable to buy and operate. In 2011, a total of 50 052 motor vehicles were registered, and approximately 80% were motorized 2- and 3-wheeled vehicles.1 Riders of such vehicles are at an increased risk of collision because the small size of the motorcycle makes them less visible to automobile drivers.3 Previous studies have shown that the human error is the most common risk factor, accounting for more than 85% of all traffic accidents.1,2,4,5 Among risky types of behavior, 3 kinds of driving behavior can increase the risks of motor vehicle crashes: running red lights, exceeding the posted speed limit, and aggressive driving.4,6 Adults aged between 15 and 44 years are considered as a vulnerable group, accounting for 59% of traffic deaths. More than three quarters (77%) of all traffic deaths occur among men.1 According to reports by the Maldivian police services, road traffic accidents have been increasing dramatically.7 Because of inadequacies in reports regarding injuries and lack of data collection system, the actual picture is not accurately reflected in the available statistics. Therefore, the aim of this study was to ascertain the incidence of and determine the risk factors for nonfatal RTIs among young adult riders in the capital city of the Maldives. The study helps provide evidence-based information about the situation regarding RTIs in the city, which could be useful to policy makers in making decisions about developing road safety strategies.
Methods This cross-sectional study was conducted during December 2012 to January 2013. Motorcyclists who were residents of Malé, aged between 18 and 44 years, and agreed to participate were recruited for this study. Ethical clearance was obtained from the Committee for Research Ethics (Social Sciences), Mahidol University, and the National Health Research Committee, Ministry of Health and Family, the Maldives. Written consent was obtained from each respondent. The sample size was calculated using a confidence interval (CI) of 95%, an acceptance error of 6%, and estimate proportion of having RTIs of 0.5. Cluster stage sampling was used to identify the study sites. Of 10 public places (markets, parks, piers) in Malé, 3 were randomly selected as sites for interviews. Trained research assistants approached every 10th motorcycle rider who entered the study sites from 9:00 am to 4:00 pm Sunday to Thursday (weekday) and from 10:00 am to 5:00 pm Friday and Saturday (weekend). On average, each respondent took 10-15 minutes to complete the questionnaire. A self-administered questionnaire was developed based on a review of the literature.8-15 The questionnaire was designed to gather the following information: (a) sociodemographic characteristics—gender, age, education, income, and occupation and (b) knowledge, attitude, and behavior related to road safety. In the section about knowledge, 15 questions were asked about safety information regarding riding motorcycles, such as using a helmet and risky driving. The total score for the knowledge part was classified into 2 categories: “good” if the score was more than 75% or >9, whereas “poor” was given to scores of equal or less than 75% or ≤9. The attitude section discussed attitudes concerning safety issues, such as wearing helmets, speeding, traffic regulations, and using handheld phones while riding a motorcycle. Scoring for each statement was 5, 4, 3, 2, and 1, corresponding to strongly agree, agree, not sure, disagree, and strongly disagree, respectively. The score was reversed for negative statements and scores ranged from 12 to 60. Total score was classified into 1 of 2 groups: “positive attitude” (more than the mean; score 42-55) and “negative attitude” (equal to or less than the mean; score 25-41). The behavior section addressed safe practices when riding, such as wearing helmets, speeding, using mobile phones, and running red lights. For this part, scoring was as follows: 5 = always, 4 = very often, 3 = sometimes, 2 = occasionally, 1 = never. Scoring was reversed for
Downloaded from aph.sagepub.com at UNIVERSITE DE MONTREAL on September 2, 2015
279
Waseela and Laosee
negative statements. The total possible score ranged from 10 to 50. Total scores were divided into 2 categories: a total score more than the mean (37-41) was considered “safe riding”; a score of less than or equal to the mean (26-36) was classified as “risky riding.” The final part of the questionnaire asked about experience of nonfatal RTIs in the 12 months prior to interview and the primary cause of injuries. The questionnaire was tested for reliability among 30 motorcyclists. The Kuder-Richardson (KR-20) test score for the knowledge section was 0.46, while Cronbach’s alphas for attitude and behavior were .69 and .70, respectively. The questionnaire was translated from English to Dhivehi, the national language. Checking the translation was done with the help of 2 local teachers to ensure that the translated questionnaire was equivalent to its English original. Univariate analysis was performed to describe the mean, standard deviation (for normal distribution variables), median, quartile deviation (for nonnormal distribution variables), minimum, maximum, number, and percentage. χ2 tests were used to determine a possible association between RTIs and each independent variable. The magnitude of association is described by odds ratio (OR) with 95% CI. Finally, a multiple logistic regression was calculated to identify the association between independent variables and risk of RTIs. To avoid distortion of the model, only males who were the majority of riders (96.6%) were included in the multiple logistic regression. A P value 10 000 ≤10 000 Occupation Private sector employee Other Years in possession of a license 1-6 7-20 Usual average speeda Excessive speed Average
Yes (%)
No (%)
Crude OR (95% CI)
P value
284 10
40.8 10.0
59.2 90.0
6.21 (0.77-49.77) 1
.08
68 226
50.0 36.7
50.0 63.3
1.72 (0.99-2.98) 1
.05
235 59
38.7 44.1
61.3 55.9
1.25 (0.70-2.22) 1
.45
178 116
40.4 38.8
59.6 61.2
1.07 (0.66-1.79) 1
.78
158 136
41.1 38.1
58.9 61.9
1.12 (0.71-1.81) 1
.61
114 178
43.0 37.1
57.0 62.9
1.27 (0.79-2.06) 1
.31
159 135
44.0 34.8
56.0 65.2
1.44 (0.92-2.36) 1
.10 (continued)
Downloaded from aph.sagepub.com at UNIVERSITE DE MONTREAL on September 2, 2015
282
Asia-Pacific Journal of Public Health 27(3)
Table 3. (continued) Traffic Injury in the Previous 12 Months Variables
n
Knowledge Good Poor Attitude Negative Positive Behavior Risky Safe
Yes (%)
No (%)
Crude OR (95% CI)
P value
71 223
45.1 38.1
54.9 61.9
1.33 (0.77-2.28) 1
.29
168 126
46.4 31.0
53.6 69.0
1.93 (1.19-3.14) 1
20 km/h) Poor level of knowledge Negative attitude toward road safety Risky riding behavior
Adjusted OR (95% CI)
P value
1.67 (0.94-2.95) 1.37 (0.84-2.24) 0.79 (0.45-1.39) 1.84 (1.11-3.03) 1.38 (0.83-2.29)
.08 .21 .42 .02 .21
Abbreviations: OR, odds ratio; CI, confidence interval.
This study indicates that young riders are 1.7 times more likely to be involved in an RTI than those older than 25 years. This finding is similar to those of studies done previously. Several studies have demonstrated that young drivers are more frequently involved in risky behavior and traffic accidents than other age-groups.6,17,18 In addition, attitude also plays a crucial role in safe riding. Our study shows that those who have a negative attitude are more likely to have RTIs. Knowledge of safe driving practices was not associated with injuries. This evidence suggests that conducting interventions to promote safety concern and focusing traffic rules among young males could be considered as the initial strategies in Malé. This study found that the primary causes of traffic injuries were a result of human factors. Deliberate traffic violations are one of the most common causes of injuries. For instance, excessive speed and violating other traffic rules were frequently cited by those who had had RTIs. The findings of our study are similar to those of a study in Taiwan that found that traffic violations increase the risk of accidents.6 However, in the capital city of Malé, the law sets the speed limit as low as 20 km/h. If riders travel at such a reduced speed, they will feel that it would take them too long to reach their destination. In this study, high number of traffic injuries were caused by excessive speed. Therefore, excessive speed in this study is not referred to as unsafe riding, like in many other countries, but as a distinct risk factor. A study of 3-wheeler taxi drivers in Sri Lanka revealed that more than half (52.9%) were categorized as aggressive driving, whereas 41% had experienced running a red light.19 Previous studies have identified various strategies against excessive speed and red light violations, such as law enforcement, penalties, and behavioral interventions.20-23 A study in Hong Kong indicated that the frequency of red light violations
Downloaded from aph.sagepub.com at UNIVERSITE DE MONTREAL on September 2, 2015
283
Waseela and Laosee
on the part of drivers significantly decreased after the introduction of demerit points and financial penalties.20 This evidence would be useful in developing a road safety strategy for Malé. Since there is no existing legislation regarding helmet use in Malé, our study is the first one that highlights the fact that none of the motorcycle riders wore helmets, even though they knew the benefits of wearing one. Other research shows that wearing a helmet reduces the risk of death in motorcycle crashes.24-27 Enforcement of the helmet act is the key to increasing the rate of helmet use.28 A study in Thailand has shown that after enforcement of the helmet act, helmet wearers increased 5-fold while head injuries decreased by 41%. Mortality decreased by 20.8%.27 Hyder et al29 concluded that enforced, mandatory motorcycle helmet laws are potentially one of the most cost-effective interventions available for low- and middle-income countries with high rates of motorcycle injuries. According to the report of global status on road safety 2013, 90 countries (77% of the world’s population) have a comprehensive helmet law, covering all riders, all roads, and all engine types. They also apply helmet manufacturing standards. In Cambodia, a law requiring motorcycle drivers to wear a helmet was passed in 2009. After the law’s adoption, approximately 60% of the drivers wear helmets. In 2010, the Cambodian government embarked on a program to increase helmet wearing through enhanced enforcement and legislation. The program includes building police capacity to enforce the law, implementing helmet check points, and revising legislation to increase penalties for noncompliance.1 The government is still working with other national partners to extend the existing helmet law to include passengers. However, passenger helmet user rates are very low (
