International Journal of Injury Control and Safety Promotion
ISSN: 1745-7300 (Print) 1745-7319 (Online) Journal homepage: http://www.tandfonline.com/loi/nics20
Vulnerability of motorcycle riders and co-riders to injuries in multi-occupant crashes Kehinde Sunday Oluwadiya, Owolabi Dele Ojo, Olayinka Oladiran Adegbehingbe, Charles Mock & Ogunsuyi Sunday Popoola To cite this article: Kehinde Sunday Oluwadiya, Owolabi Dele Ojo, Olayinka Oladiran Adegbehingbe, Charles Mock & Ogunsuyi Sunday Popoola (2014): Vulnerability of motorcycle riders and co-riders to injuries in multi-occupant crashes, International Journal of Injury Control and Safety Promotion, DOI: 10.1080/17457300.2014.969280 To link to this article: http://dx.doi.org/10.1080/17457300.2014.969280
Published online: 06 Nov 2014.
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Date: 06 November 2015, At: 20:36
International Journal of Injury Control and Safety Promotion, 2014 http://dx.doi.org/10.1080/17457300.2014.969280
Vulnerability of motorcycle riders and co-riders to injuries in multi-occupant crashes Kehinde Sunday Oluwadiyaa*, Owolabi Dele Ojob, Olayinka Oladiran Adegbehingbec, Charles Mockd and Ogunsuyi Sunday Popoolaa a
Department of Surgery, Ekiti State University, Ado-Ekiti, Nigeria; bDepartment of Surgery, Federal Medical Center, Ido-Ekiti, Nigeria; c Department of Orthopedics and Traumatology, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria; d Harborview Injury Prevention and Research Center, University of Washington, Seattle WA, USA
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(Received 17 April 2014; accepted 19 September 2014) In developing countries, most motorcycles are ridden with more than one occupant. The objective of this study was to establish the relative vulnerability of riders and co-riders to injury and determine the injury risk factors in multi-occupant motorcycle crashes. Between January and December 2010, we collected crash and injury data from victims of multioccupant motorcycle. It is a hospital-based study. The probability of sustaining injuries was similar for co-riders and riders, but co-riders were more likely to sustain severe injuries. Occupants of >2-occupant motorcycles were also more likely to be involved in risky behaviours like not wearing helmet and speeding than those on 2-occupant motorcycles. Occupants of motorcycles on which there were more than two occupants were at an increased risk of sustaining injuries compared with occupants of motorcycles with only two occupants (OR: 2.1, 95% CI: 1.1 4.3). Motorcycle co-riders were more vulnerable to severe injuries than riders. The significance of the study finding to prevention was discussed. Keywords: motorcycle crash; motorcycle injury; injury epidemiology; Nigeria; developing country
Introduction From the 11th position which it occupied in the first two years of the last decade, road traffic injury (RTI) is expected to become the 6th leading cause of death by the end of the present decade (Peden et al., 2004). Thus, within two decades, the number of deaths and injuries due to RTI is expected to have risen by an estimated 65% worldwide (Peden et al., 2004). Most of this increase is expected to be in low- and middle-income countries (LMICs) (Peden et al., 2004; Peden & Hyder, 2002), which is probably due to the increasing popularity of motorcycles in these countries (Hung, Stevenson, & Ivers, 2008; Peden et al., 2004; Oluwadiya et al., 2009). For example, in Nigeria, 52% of all motor vehicle licence plates issued between 2004 and 2005 were for motorcycles (Federal Road Safety Commission, 2006). In Philippines and China, comparative figures were 48% in 2007 and 63.2% in 2001, respectively (Virola, 2009; Zhang et al., 2004). In many of these countries, the motorcycles were increasingly being used for commercial commuting purposes (Hung et al., 2008; Oluwadiya et al., 2009; Zhang et al., 2004). This is a frightening development because motorcycles are inherently less safe than motor vehicles (Bothwell, 1962). It had been estimated that in crashes involving motorcycles and cars, motorcyclists were about 35 times more likely to be killed than car
occupants, and eight times more likely to be injured (National Highway Traffic Safety Administration, 2007). In high-income countries (HICs), where motorcycles are ridden for recreational/sport purposes, most motorcycle crashes involved only the rider, who is almost always the only occupant (Association of European Motorcycle Manufacturers [ACEM], 2009). However, in LMICs, where motorcycles are vital parts of private and commercial commuting in both rural and urban areas, motorcycle crashes most often involve more than one occupant on the vehicle (Adegbehingbe, Oluwadiya, & Adegbehingbe, 2004; Hung et al., 2008; Oluwadiya et al., 2009; Oluwadiya, Oginni, Fadiora, & Olasinde, 2004; Solagberu et al., 2006; Zhang et al., 2004). Road crashes are secondary to factors that can be categorized into human factors (road users), vehicle factors, and environment (road) factors. The number of persons on a motorcycle and the size of luggage (if there is any) are two important factors that may affect the handling and stability of motorcycles (ACEM, 2009; Kraus et al., 1991). When a rider takes on a co-rider, he could have more difficulty steering the motorcycle due to increased inertia. In addition, postural changes by the co-rider could also adversely affect the stability of the motorcycle (Koizumi, Tsujiuchi, Ezaki, & Yasunobe, 2008). These effects are worsened when more than one co-rider is carried, or
*Corresponding author. Email: [email protected]; [email protected] Ó 2014 Taylor & Francis
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the motorcycle is loaded with baggage; a situation which is very common in many low-income countries (Oluwadiya et al., 2004). Given that in LMICs, there is increasing use of motorcycles as commercial taxis, which most times have more than one occupant, it is important to learn more about risk factors for injuries in such situations. This was a hospitalbased study of victims of motorcycle crashes occurring with two or more occupants on the involved motorcycles. The primary objective of the research was to establish the relative vulnerability of riders and co-riders to injury. The secondary objectives were to investigate the factors that determine crash outcomes (injured versus uninjured) in multi-occupant motorcycle crashes. Findings from this study would provide information that could be useful in reducing motorcycle crash injuries (MCI) in resourcepoor settings. Method This was a prospective study of patients with MCIs presenting at the accident and emergency facilities of LAUTECH Teaching Hospital, Osogbo, and Federal Medical Centre Ido-Ekiti for a one-year period between 1 January and 31 December 2010. The study centres were tertiary hospitals which were referral centres for all patients from Osun, Oyo, Ekiti, and Ondo States in southwest Nigeria. Nigeria is divided into 36 states and a federal capital territory, and has a population of 140 million (Federal Government of Nigeria, 2007). At the time of the study, the population living within the catchment area of the hospitals was about 8 million. The Nigerian national health system has three tiers of health care: primary, secondary, and tertiary. The tertiary health centres are teaching hospitals and federal medical centres, which serve as referral centres for the remaining two tiers. Patients with moderate to severe traumatic injuries needing advanced care (for example, neurosurgical and cardiothoracic) are referred to tertiary healthcare facilities. In theory, only patients with moderate to severe injuries should be taken to such centres, but in reality, almost all trauma patients, the severity of injury notwithstanding; are taken to tertiary hospitals. We designed a data collection form for collecting data from the patients (or/and their companions) after resuscitation in the Accident & Emergency wards (A&E) of the participating hospitals. The data were extracted by resident doctors as a part of the routine procedures for the patients. The data collected were patient’s biodata, the injury sustained (if any), crash location, details of the crash, number of persons on the motorcycle at the time of the crash, mode of involvement of patient (rider or corider), sitting position of the patient and, the use of helmets. Alcohol use by riders was based on either selfreports or reports of the riders’ companions. Other data on
the form included the model, model-year, and engine capacities of the motorcycles as well as the riding experiences of the riders. The data collection form had to be filled for all occupants of the crashed motorcycle whether injured or not. For uninjured occupants, the crash outcome was entered as ‘not injured’ and all injury and treatment items on their data collection form were entered as ‘not applicable’. Data from crashes in which information could not be obtained for all occupants on the involved motorcycles were discarded. The patients gave their informed consents. In this study, the term occupant refers to both the rider and the co-rider. The study was approved by the LAUTECH Ethical Committee. Data analysis The injury severity score (ISS) for each patient was based on the abbreviated injury score 1990 version (AIS90) (Association for the Advancement of Automotive Medicine, 1998; Baker, O’Neill, Haddon, & Long, 1974). The AIS grades each injury by severity from 1 (least severe) to 5 (survival uncertain), within six body regions (head/ neck, face, chest, abdominal/pelvic contents, extremities, and skin/general. The AIS does not reflect the combined effect of multiple injuries, but it forms the basis of ISS. ISS is calculated by aggregating the square of the highest AIS scores in the three most severely injured regions. ISS scores range from 1 to 75. By convention, an AIS score of 6 (defined as a non-survivable injury) for any region becomes an ISS of 75. Moderate and severe injuries were defined as ISS of 9 15 and ISS 16, respectively. We analysed the data in two batches. In the first batch, we analysed all the crash events involving multiple occupants together. We looked at the distribution of the data using frequency tables as well as measures of central tendencies and dispersion. We also compared demographic and injury data among riders and co-riders using relative risks (RR) and we used chi-square to compare categorical variables. When the RR could not be defined because value in one of the cells was 0, we calculated absolute risk reduction (ARR) instead. Finally, we identified factors predictive of injury in motorcycle crashes using logistic regression. The dependent variable was crash outcome (injured versus not injured) while the independent or predictive variables were the factors which were found to be significant in univariate chi-square analysis. For the second batch, we separated the data into two groups: 2-occupant crash and >2-occupant crash. We then compared crash event data and injury outcome data among the two groups using RR. Co-riders were the reference group. We used PASW Statistics 18 (SPSS, 2009) for data entry and all statistical analysis except for RR which we calculated with MedCalc 10 (Schoonjans, 2009).
International Journal of Injury Control and Safety Promotion Results
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There were 125 crashes within the study period. Two hundred and twenty-nine patients were injured in the crashes. However, 47 (37.6%) of the crashes involved motorcycles carrying only the rider at the time of the crash, while the remaining 78 (62.4%) involved crashed motorcycles with two or more occupants. The victims of the 78 multi-occupant crashes were the subjects of this study.
Batch 1 analysis Of the 78 crashes involving motorcycles with two or more occupants, 42 (53.8%) caused injuries to riders and coriders together, 24 (30.8%) caused injuries to co-riders alone, while 12 (15.4%) caused injuries to riders alone. A total of 181 persons were involved in these crashes out of which 126 (69.6%) sustained injuries while the remaining 55 (30.4%) escaped unhurt. The 126 injured motorcycle occupants were made up of 53 (42.1%) riders and 73 (57.9%) co-riders. All the riders were males. Table 1 shows the result of statistical analysis of the 78 crash events with multiple occupants (Batch 1). In 18 (23.1%) of these crashes, the crashed motorcycles had more than two occupants during the crash event (in five cases, one of the co-riders sat on the fuel tank). All the motorcycles were small, Asian models with engine capacities ranging from 0.8 to 1.20 litres, most of which were more than five years old. The median riding experience of the riders of the motorcycles was 4 years (range: 5 months to 34 years). Helmet use was very poor as 2-occupant motorcycles compared to 2-occupant motorcycles. Also, 2-occupant motorcyclists were more than seven times more likely to be wearing helmets than >2-occupant motorcyclists. However, riders of 2-occupant motorcycles were 1.8 times less likely to be licensed than riders of >2occupant motorcycles. There was no significant difference in the severity of injuries sustained by persons on 2- and >2-occupant motorcycles. In Table 6, we went further to compare injury and demographic data among patients injured on 2- and >2occupant motorcycle crashes on the basis of their involvement as operators or co-riders. Our aim was to find whether there was a difference in the vulnerability of occupants in these two categories (2 occupants and >2 occupants) when a motorcycle crash occurs. In 2-occupant crash events, the ARR for severe injury in riders
Table 4. Distribution of injuries according to the body regions among riders and co-riders. Body region (N) Head (N D 36) Face (N D 34) Chest (N D 8) Abdomen (N D 2) Extremities (N D 80) External (N D 41)
Rider (% within body region)
Co-rider (% within body region)
p-value
11 (30.5) 17 (50.0) 5 (62.5) 1 (50.0) 25 (31.3) 22 (53.7)
25 (69.5) 17 (50.0) 3 (37.5) 1 (50.0) 55 (68.7) 19 (46.3)
0.098 0.274 0.230 0.820 0.001 0.051
Note: N D total number of patients with injuries to the body region.
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Table 5. Demographic and injury data in crashes involving 2-occupant and >2-occupant motorcycles.
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Attribute
>2-occupant crashes (%)
Injury severity (n D 126) Severe (ISS 16) Mild/moderate (ISS 15) Driver licensing (n D 140) Licensing status Licensed Not licensed Helmet use (n D 162) Yes No Gender Male Female Alcohol Yes No Unknown Speed perception Slow/moderate Fast/very fast Others Mean age Mean ISS Mean RTS
2-occupant crashes (%)
Relative risk (95% CI)
P-value
3 (8.1) 34 (91.9)
4 (4.5) 85 (95.5)
1.8 (0.42 7.67)
0.42
26 (50.0) 26 (50.0)
24 (27.3) 64 (72.7)
1.8 (1.19 2.84)
0.007
1 (1.8) 55 (98.2)
14 (13.2) 92 (86.8)
0.14 (0.02 1.0)
0.05
49 (80.3) 12 (19.7)
109 (90.8) 11 (12.2)
0.045
2 (3.3) 57 (93.4) 2 (3.3)
18 (15.0) 98 (81.7) 4 (3.3)
0.058
19 (31.1) 42 (58.9)
66 (58.9) 47 (40.1)
2-occupants
2-occupants Attribute Crash outcome Sustained injuries Did not sustain injuries Injury severity (n D 126) Severe (ISS 16) Mild/moderate (ISS 15) Helmet use Yes No Others Mean age Mean ISS Mean RTS
Co-rider (n D 60)
Rider (n D 60)
Co-rider (n D 43)
Rider (n D 18)
48 (80.0%) 30 (20.0%)
41(68.3%) 25(31.7%)
.99(0.76 1.28)
25 (58.1%) 18 (41.9)
12 (66.7%) 6 (33.3%)
0.87 (0.58 1.3)
4 (8.3%) 44 (91.7%)
0.0 41 (100%)
a
3 (12.0) 22 (88.0)
0.0 12 (100%)
b
9 (9.4%) 87 (90.6%)
6.0 (9.1%) 60 (90.9%)
c
0.0 40 (100%)
1.0 (6.3%) 15 (93.8%)
d
33.9 8.4e 7.3740
33.7 4.6e 7.7902
23.0 11.6e 7.1726
27.1 3.6e 7.5069
RR (95% CI)
1.03 (0.38 2.75)
RR is undefined as one of the cells has 0 value. ARR is ¡0.083 (CI: ¡0.083 to 0.024). Relative risk is undefined as one of the cells has 0 value. However ARR is ¡0.12 (¡0.012 to 0.0129). c ARR is ¡0.021 (¡0.255 to 0.275). This ARR was calculated to make comparison with the ARR in d easier. d Relative risk is undefined as one of the cells has 0 value. However risk difference is 0.714 (¡0.248 to 0.714). e p < 0.05. a
b
RR
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K.S. Oluwadiya et al.
compared to co-riders was 0.083. That is, if 1000 co-riders in a 2-occupant crash event had been involved as riders, then there would have been 83 less patients with severe injuries. For >2-occupant crash events, the risk reduction was a third more than in 2-occupant crash events (i.e. 120 less patients with severe injuries). The risk reduction of wearing helmet is even more strikingly different between co-riders and riders of 2-occupant and >2-occupant crashes. The ARR in >2-occupant crashes was 0.714, which means that if 1000 co-riders who were involved in the crash event had been involved as riders, then 714 more of the victims would have been wearing helmets. Whereas, for 2-occupant situations, the ARR was ¡0.021, meaning that if 1000 co-riders who were involved in the crash event had been involved as riders, then a further 21 of the victims would NOT have been wearing helmets. Also, of the 16 persons who were wearing helmets when the crashes occurred, 15 (93.4%) of them occurred on 2occupant motorcycles. Discussion Crashes involving motorcycles with multiple occupants accounted for more than 60% of patients injured in motorcycle crashes presenting to the study hospitals. This emphasizes one of the major differences between motorcycle usages in resource-poor settings compared to HICs. In HICs where motorcycles are mostly used for recreational purposes (Hurt, Ouellet, & Thom, 1981), most motorcycle crashes involved single-occupant motorcycles. For example, in the Motorcycle Accidents In Depth Study (MAIDS), only 8.7% of crashed motorcycles were carrying a co-rider (ACEM, 2009). On the other hand, in LMICs, riding motorcycles is a means of living and a necessary part of daily commuting to and from work (Oluwadiya, 2010b). Many are used for commercial commuting and their operators have strong motivations for profit (Oluwadiya et al., 2009), therefore the more coriders they ferry, the greater their profit. This profit motivated drive may be the reason why 23.1% of the motorcycles in this study were carrying more than the two recommended persons (the rider and one co-rider) when the crash occurred. In the MAIDS study, none of the motorcycles involved in the study was carrying more than two occupants (Association for the Advancement of Automotive Medicine, 1998). The injured patients in this study comprised 42.1% riders and 57.9% co-riders. This is contrary to the findings from previous MCI studies in Nigeria, in which riders had always been reported as being more commonly injured than co-riders (Adegbehingbe et al., 2004; Nzegwu, Aligbe, Banjo, Akhiwui, & Nzegwu, 2008; Oginni, Ajike, Obuekwe, & Fasola, 2009; Oluwadiya et al., 2009; Oluwadiya et al., 2004; Solagberu et al., 2006). For example, of all injured patients in the study reported by Solagberu
et al. (2006), 53.6% were riders, 32.1% co-riders, and 14.3% pedestrians, and in the series by Oginni et al. (2009), 62.4% of the injured patients were riders, 25.3% were co-riders, and 12.2% were pedestrians. While these studies showed that overall, riders were injured more than other categories of motorcycle crash victims, it may not be a true reflection of the relative vulnerability of the different categories of motorcycle crash victims to injury. By necessity, all motorcycle crashes must involve a rider, but not all will involve co-riders. Therefore, riders experience more crash events than other categories of road users. For example, all previous studies from Nigeria included single-occupant motorcycle crashes. Our study, on the other hand, focused exclusively on crashes involving motorcycles with multiple occupants. It should serve as a true reflection of risk to riders versus risk to co-riders in such situations. Our study showed that, overall, the risks of sustaining injuries in riders and co-riders are similar. However, when only severe injuries were considered, co-riders had a greater risk of sustaining severe injuries than riders. Reasons for the increased vulnerability of co-riders to sustaining severe injuries might have been because co-riders were less likely to wear helmets. The other probable reason was that riders being in control of the motorcycles were probably more likely than co-riders to be alert, and as a result, be better prepared to brace themselves for crash impacts; and thus, sustain less severe injuries. The number of occupants was the only significant predictor of injury in the logistic regression. Motorcycles are designed in such a way that they handle and perform optimally within certain specifications (ACEM, 2009). With this in mind, motorcycles are designed to perform optimally when carrying one or two persons. Even then, taking on the suggested one passenger may actually increase the risk of crash. For instance, the MAIDS study found that 17.8% of crashes involving motorcycles carrying (one) pillion passengers were cases ‘where the passenger suddenly shifted, causing a control instability in the motorcycle and cases where the passenger had distracted the motorcycle operator, causing an accident’ (ACEM, 2009). The handling dynamics can only be worsened with more than two occupants on the motorcycles. In some cases, extra co-rider(s) were seated on the fuel tank in front of the rider, which may block the rider’s view. In Nigeria, it is illegal for motorcyclists to take more than one co-rider at a time (Federal Road Safety Commission, 1997). Yet this study shows that it is a common occurrence on Nigerian roads as more than one out of every five patients included in the study were injured on motorcycles with three or more occupants. One reason for this risky behaviour may be because the motorcycle riders, who were mostly commercial motorcyclists, were under intense pressures to turn profit (Oluwadiya et al., 2009). The other reason may be age-related. The mean age of
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International Journal of Injury Control and Safety Promotion patients injured on motorcycles with two or more occupants was almost 10 years younger than the mean age of those injured on motorcycles with two occupants. This is in agreement with studies over the world which shows that young road users are more likely to take risky decisions than older road users (Brown & Groeger, 1988; Deery, 1999; Nell, 2002). Why were riders of 2-occupant motorcycles involved in crashes 1.8 times less likely to be licensed compared to riders on >2-occupant motorcycles? This counter-intuitive finding might not be very reliable because the respondents may have lied about the licensing status of motorcycle riders. A previous communitybased study of motorcycle riders from the same region had shown that only 14 riders out of 37 who had previously claimed to have driving licence were able to produce them when asked to do so (Oluwadiya, 2010b). Persons on >2-occupant motorcycles, some of whom were teenagers may have lied to the contrary, either out of fear or to avoid chastisements, when they knew (or were not sure) that the riders of their motorcycles were not licensed. On the other hand, persons on 2-occupant motorcycles, who were on the average, almost a decade older than those on >2-occupant motorcycles may have been more likely to tell the truth when they knew their riders were not licensed. Even though there is a helmet law in place in Nigeria, adherence to the law had been very poor (Oginni et al., 2009; Oluwadiya et al., 2009; Oluwadiya et al., 2004; Solagberu et al., 2006). A subtle cause of this poor adherence is when riders take on more than one co-rider on the motorcycle. The law stipulates that a commercial motorcyclist should have two helmets with him always; one for the rider and the other for the co-rider. In a situation where there were more than two co-riders on the motorcycle, it meant one of the co-riders had to do without a helmet. Additionally, taking on more than the legal one co-rider may be a pointer to other risky behaviours taken by motorcyclists. As extrapolated from our data, only one (1.7%) out of the 59 patients injured on >2-occupant motorcycle crashes was helmeted compared to 16 (13.3%) out of the 120 who were injured in 2-occupant crashes. Second, in contrast to the 2-occupant crashes that occurred, a significantly higher proportion of those injured on >2-occupant crashes occurred while the motorcycle was perceived to have been moving too fast. Because of the increasing popularity of motorcycles for transport, it is likely that the problem of motorcycle injuries will continue to increase in future. Data from the Federal Road Safety Commission, the federal government agency saddled with the responsibility of maintaining road safety in Nigeria showed more than a 10-fold increase in motorcycle registration between 1991 and 1998 (Oyesiku, 2002). Similarly, in 2004, 52% of all motor vehicle licence plates issued in Nigeria were for
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motorcycles (Federal Road Safety Commission, 2006). A recent review of Nigerian literature on trauma over the last four decades showed that motorcycle injuries have increased six times from 6.2% of all RTIs in the 1970s to 36.3% between 2000 and 2009 (Oluwadiya, 2010a). It is therefore important to find ways to reduce the crash rate in order to avoid the anticipated increase in motorcycle injuries. Some studies have shown that the fear of personal injuries can be a powerful incentive to adopting safety practices in driving (Kizer & Trent, 1991; Nell, 2002). Therefore, referencing this study and others like it, and publicizing the fact that motorcycle riders stood a higher risk of sustaining severe injuries in crashes when carrying more than the legal one pillion passenger can be used to encourage them to comply with the law. Furthermore, the results of our study can be used to persuade coriders to avoid overloaded motorcycles. A simple message such as ‘carrying more than one co-rider on a moving motorcycle doubles your risk of sustaining serious injuries’ can be broadcasted by mass media to encourage motorcycle users to be more compliant and consequently reduce the incidence of injuries associated with multioccupant motorcycle crashes. There are few studies of the effectiveness of mass media campaign in reducing road traffic related morbidity and mortality in developing countries and none, to our knowledge, for Nigeria. However, maternal and reproductive health studies have shown that mass media campaigns can produce positive changes or reduce negative health related behaviours among Nigerians (Keating, Meekers, & Adewuyi, 2006; Piotrow et al., 1990). Finally there should be a major improvement in the enforcement of traffic rules and regulations because this has been shown to be the most important way of ensuring safe motoring. Based on the findings in this study, we suggest that law enforcement agents take more interest in preventing >2-occupant motorcycle riding, as this will have the twin benefits of improving helmet use and reducing severe injuries. The limitations of this study stemmed from the fact that it is a hospital-based study of injured motorcyclists. Hospital-based data acquisition commonly excludes onscene deaths and some with mild to moderate injuries. In addition, some patients may have sought treatments at other health care facilities apart from the tertiary health centres where the study took place. Thus it is possible that the incidence of MCIs recorded in this study may be lower than the true population estimate, and the data might have been skewed towards more severe injuries. This effect could have been mitigated by the fact that most victims of road crashes in Nigeria are taken directly to the nearest tertiary health centres. Finally, in the data poor setting of the study, hospital-based studies are commonly the most reliable source of realistic data on injuries and their causes.
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Acknowledgements The authors wish to thank Miss Hauwa Adeniji for assisting in proof reading the manuscript.
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Nell, V. (2002). Why young men drive dangerously: Implications for injury prevention. Current Directions in Psychological Science, 11(2), 75 79. Nzegwu, M., Aligbe, J., Banjo, A., Akhiwui, W., & Nzegwu, C. (2008). Patterns of morbidity and mortality amongst motorcycle riders and their passengers in Benin-City Nigeria: One-year review. Annals of African Medicine, 7(2), 82 85. Oginni, F., Ajike, S., Obuekwe, O., & Fasola, O. (2009). A prospective multicenter study of injury profile, severity and risk factors in 221 motorcycle-injured Nigerian maxillofacial patients. Traffic Injury Prevention, 10(1), 70 75. Oluwadiya, K.S. (2010a). Pattern of traumatic injuries in Nigeria: A review. Nigerian Journal of Clinical and Biomedical Research, 5(1), 13 22. Oluwadiya, K.S. (2010b). The performance of the motorcycle rider behaviour questionnaire among commercial motorcycle riders in Nigeria. In L. Dorn (Ed.), Driver behaviour and training (Vol. IV, pp. 193 209). Surrey: Ashgate. Oluwadiya, K.S., Kolawole, I.K., Adegbehingbe, O.O., Olasinde, A.A., Agodirin, O., & Uwaezuoke, S.C. (2009). Motorcycle crash characteristics in Nigeria: Implication for control. Accident Analysis & Prevention, 41(2), 294 298. doi:S0001-4575(08)00235-2 [pii] 10.1016/j.aap.2008.12.002 Oluwadiya, K.S., Oginni, L.M., Fadiora, S.O., & Olasinde, O.O. (2004). Epidemiology of motorcycle injuries in a developing country. West Africa Journal of Medicine, 23(1), 42 47. Oyesiku, O. (2002). Policy framework for urban motorcycle public transport system in Nigerian cities. In X. Godard & I. Fatonzoun (Eds.), Urban mobility for all (pp. 255 261). London: Taylor & Francis. SPSS. (2009). PASW Statistics 18 [Computer software]. Chicago, IL. Peden, M., & Hyder, A. (2002). Road traffic injuries are a global public health problem. BMJ, 324(7346), 1153. Peden, M., Scurfield, R., Sleet, D., Mohan, D., Hyder, A.A., Jarawan, E., & Mathers, C. (2004). World report on road traffic injury prevention. Geneva: World Health Organization. Piotrow, P.T., Rimon, J.G., Winnard, K., Kincaid, D.L., Huntington, D., & Convisser, J. (1990). Mass media family planning promotion in three Nigerian cities. Studies in Family Planning, 21(5), 265 274. Schoonjans, F. (2009). MedCalc software (Version 10.2). Mariakerke, Belgium. Solagberu, B., Ofoegbu, C., Nasir, A., Ogundipe, O., Adekanye, A., & Abdur-Rahman, L. (2006). Motorcycle injuries in a developing country and the vulnerability of riders, passengers, and pedestrians. Injury Prevention, 12(4), 266 268. Virola, R.A. (2009). Land transport in the Philippines: Retrogressing towards motorcycles? Retrieved July 28, 2011, from http://www.nscb.gov.ph/headlines/StatsSpeak/2009/ 101209_rav_raab_trans.asp#f1 Zhang, J., Norton, R., Tang, K.C., Lo, S.K., Jiatong, Z., & Wenkui, G. (2004). Motorcycle ownership and injury in China. Injury Control and Safety Promotion, 11(3), 159 163. doi:Q84UEMWHM2N21ELL [pii] 10.1080/ 156609704/233/289643
ISSN: 1745-7300 (Print) 1745-7319 (Online) Journal homepage: http://www.tandfonline.com/loi/nics20
Vulnerability of motorcycle riders and co-riders to injuries in multi-occupant crashes Kehinde Sunday Oluwadiya, Owolabi Dele Ojo, Olayinka Oladiran Adegbehingbe, Charles Mock & Ogunsuyi Sunday Popoola To cite this article: Kehinde Sunday Oluwadiya, Owolabi Dele Ojo, Olayinka Oladiran Adegbehingbe, Charles Mock & Ogunsuyi Sunday Popoola (2014): Vulnerability of motorcycle riders and co-riders to injuries in multi-occupant crashes, International Journal of Injury Control and Safety Promotion, DOI: 10.1080/17457300.2014.969280 To link to this article: http://dx.doi.org/10.1080/17457300.2014.969280
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Date: 06 November 2015, At: 20:36
International Journal of Injury Control and Safety Promotion, 2014 http://dx.doi.org/10.1080/17457300.2014.969280
Vulnerability of motorcycle riders and co-riders to injuries in multi-occupant crashes Kehinde Sunday Oluwadiyaa*, Owolabi Dele Ojob, Olayinka Oladiran Adegbehingbec, Charles Mockd and Ogunsuyi Sunday Popoolaa a
Department of Surgery, Ekiti State University, Ado-Ekiti, Nigeria; bDepartment of Surgery, Federal Medical Center, Ido-Ekiti, Nigeria; c Department of Orthopedics and Traumatology, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria; d Harborview Injury Prevention and Research Center, University of Washington, Seattle WA, USA
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(Received 17 April 2014; accepted 19 September 2014) In developing countries, most motorcycles are ridden with more than one occupant. The objective of this study was to establish the relative vulnerability of riders and co-riders to injury and determine the injury risk factors in multi-occupant motorcycle crashes. Between January and December 2010, we collected crash and injury data from victims of multioccupant motorcycle. It is a hospital-based study. The probability of sustaining injuries was similar for co-riders and riders, but co-riders were more likely to sustain severe injuries. Occupants of >2-occupant motorcycles were also more likely to be involved in risky behaviours like not wearing helmet and speeding than those on 2-occupant motorcycles. Occupants of motorcycles on which there were more than two occupants were at an increased risk of sustaining injuries compared with occupants of motorcycles with only two occupants (OR: 2.1, 95% CI: 1.1 4.3). Motorcycle co-riders were more vulnerable to severe injuries than riders. The significance of the study finding to prevention was discussed. Keywords: motorcycle crash; motorcycle injury; injury epidemiology; Nigeria; developing country
Introduction From the 11th position which it occupied in the first two years of the last decade, road traffic injury (RTI) is expected to become the 6th leading cause of death by the end of the present decade (Peden et al., 2004). Thus, within two decades, the number of deaths and injuries due to RTI is expected to have risen by an estimated 65% worldwide (Peden et al., 2004). Most of this increase is expected to be in low- and middle-income countries (LMICs) (Peden et al., 2004; Peden & Hyder, 2002), which is probably due to the increasing popularity of motorcycles in these countries (Hung, Stevenson, & Ivers, 2008; Peden et al., 2004; Oluwadiya et al., 2009). For example, in Nigeria, 52% of all motor vehicle licence plates issued between 2004 and 2005 were for motorcycles (Federal Road Safety Commission, 2006). In Philippines and China, comparative figures were 48% in 2007 and 63.2% in 2001, respectively (Virola, 2009; Zhang et al., 2004). In many of these countries, the motorcycles were increasingly being used for commercial commuting purposes (Hung et al., 2008; Oluwadiya et al., 2009; Zhang et al., 2004). This is a frightening development because motorcycles are inherently less safe than motor vehicles (Bothwell, 1962). It had been estimated that in crashes involving motorcycles and cars, motorcyclists were about 35 times more likely to be killed than car
occupants, and eight times more likely to be injured (National Highway Traffic Safety Administration, 2007). In high-income countries (HICs), where motorcycles are ridden for recreational/sport purposes, most motorcycle crashes involved only the rider, who is almost always the only occupant (Association of European Motorcycle Manufacturers [ACEM], 2009). However, in LMICs, where motorcycles are vital parts of private and commercial commuting in both rural and urban areas, motorcycle crashes most often involve more than one occupant on the vehicle (Adegbehingbe, Oluwadiya, & Adegbehingbe, 2004; Hung et al., 2008; Oluwadiya et al., 2009; Oluwadiya, Oginni, Fadiora, & Olasinde, 2004; Solagberu et al., 2006; Zhang et al., 2004). Road crashes are secondary to factors that can be categorized into human factors (road users), vehicle factors, and environment (road) factors. The number of persons on a motorcycle and the size of luggage (if there is any) are two important factors that may affect the handling and stability of motorcycles (ACEM, 2009; Kraus et al., 1991). When a rider takes on a co-rider, he could have more difficulty steering the motorcycle due to increased inertia. In addition, postural changes by the co-rider could also adversely affect the stability of the motorcycle (Koizumi, Tsujiuchi, Ezaki, & Yasunobe, 2008). These effects are worsened when more than one co-rider is carried, or
*Corresponding author. Email: [email protected]; [email protected] Ó 2014 Taylor & Francis
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K.S. Oluwadiya et al.
the motorcycle is loaded with baggage; a situation which is very common in many low-income countries (Oluwadiya et al., 2004). Given that in LMICs, there is increasing use of motorcycles as commercial taxis, which most times have more than one occupant, it is important to learn more about risk factors for injuries in such situations. This was a hospitalbased study of victims of motorcycle crashes occurring with two or more occupants on the involved motorcycles. The primary objective of the research was to establish the relative vulnerability of riders and co-riders to injury. The secondary objectives were to investigate the factors that determine crash outcomes (injured versus uninjured) in multi-occupant motorcycle crashes. Findings from this study would provide information that could be useful in reducing motorcycle crash injuries (MCI) in resourcepoor settings. Method This was a prospective study of patients with MCIs presenting at the accident and emergency facilities of LAUTECH Teaching Hospital, Osogbo, and Federal Medical Centre Ido-Ekiti for a one-year period between 1 January and 31 December 2010. The study centres were tertiary hospitals which were referral centres for all patients from Osun, Oyo, Ekiti, and Ondo States in southwest Nigeria. Nigeria is divided into 36 states and a federal capital territory, and has a population of 140 million (Federal Government of Nigeria, 2007). At the time of the study, the population living within the catchment area of the hospitals was about 8 million. The Nigerian national health system has three tiers of health care: primary, secondary, and tertiary. The tertiary health centres are teaching hospitals and federal medical centres, which serve as referral centres for the remaining two tiers. Patients with moderate to severe traumatic injuries needing advanced care (for example, neurosurgical and cardiothoracic) are referred to tertiary healthcare facilities. In theory, only patients with moderate to severe injuries should be taken to such centres, but in reality, almost all trauma patients, the severity of injury notwithstanding; are taken to tertiary hospitals. We designed a data collection form for collecting data from the patients (or/and their companions) after resuscitation in the Accident & Emergency wards (A&E) of the participating hospitals. The data were extracted by resident doctors as a part of the routine procedures for the patients. The data collected were patient’s biodata, the injury sustained (if any), crash location, details of the crash, number of persons on the motorcycle at the time of the crash, mode of involvement of patient (rider or corider), sitting position of the patient and, the use of helmets. Alcohol use by riders was based on either selfreports or reports of the riders’ companions. Other data on
the form included the model, model-year, and engine capacities of the motorcycles as well as the riding experiences of the riders. The data collection form had to be filled for all occupants of the crashed motorcycle whether injured or not. For uninjured occupants, the crash outcome was entered as ‘not injured’ and all injury and treatment items on their data collection form were entered as ‘not applicable’. Data from crashes in which information could not be obtained for all occupants on the involved motorcycles were discarded. The patients gave their informed consents. In this study, the term occupant refers to both the rider and the co-rider. The study was approved by the LAUTECH Ethical Committee. Data analysis The injury severity score (ISS) for each patient was based on the abbreviated injury score 1990 version (AIS90) (Association for the Advancement of Automotive Medicine, 1998; Baker, O’Neill, Haddon, & Long, 1974). The AIS grades each injury by severity from 1 (least severe) to 5 (survival uncertain), within six body regions (head/ neck, face, chest, abdominal/pelvic contents, extremities, and skin/general. The AIS does not reflect the combined effect of multiple injuries, but it forms the basis of ISS. ISS is calculated by aggregating the square of the highest AIS scores in the three most severely injured regions. ISS scores range from 1 to 75. By convention, an AIS score of 6 (defined as a non-survivable injury) for any region becomes an ISS of 75. Moderate and severe injuries were defined as ISS of 9 15 and ISS 16, respectively. We analysed the data in two batches. In the first batch, we analysed all the crash events involving multiple occupants together. We looked at the distribution of the data using frequency tables as well as measures of central tendencies and dispersion. We also compared demographic and injury data among riders and co-riders using relative risks (RR) and we used chi-square to compare categorical variables. When the RR could not be defined because value in one of the cells was 0, we calculated absolute risk reduction (ARR) instead. Finally, we identified factors predictive of injury in motorcycle crashes using logistic regression. The dependent variable was crash outcome (injured versus not injured) while the independent or predictive variables were the factors which were found to be significant in univariate chi-square analysis. For the second batch, we separated the data into two groups: 2-occupant crash and >2-occupant crash. We then compared crash event data and injury outcome data among the two groups using RR. Co-riders were the reference group. We used PASW Statistics 18 (SPSS, 2009) for data entry and all statistical analysis except for RR which we calculated with MedCalc 10 (Schoonjans, 2009).
International Journal of Injury Control and Safety Promotion Results
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There were 125 crashes within the study period. Two hundred and twenty-nine patients were injured in the crashes. However, 47 (37.6%) of the crashes involved motorcycles carrying only the rider at the time of the crash, while the remaining 78 (62.4%) involved crashed motorcycles with two or more occupants. The victims of the 78 multi-occupant crashes were the subjects of this study.
Batch 1 analysis Of the 78 crashes involving motorcycles with two or more occupants, 42 (53.8%) caused injuries to riders and coriders together, 24 (30.8%) caused injuries to co-riders alone, while 12 (15.4%) caused injuries to riders alone. A total of 181 persons were involved in these crashes out of which 126 (69.6%) sustained injuries while the remaining 55 (30.4%) escaped unhurt. The 126 injured motorcycle occupants were made up of 53 (42.1%) riders and 73 (57.9%) co-riders. All the riders were males. Table 1 shows the result of statistical analysis of the 78 crash events with multiple occupants (Batch 1). In 18 (23.1%) of these crashes, the crashed motorcycles had more than two occupants during the crash event (in five cases, one of the co-riders sat on the fuel tank). All the motorcycles were small, Asian models with engine capacities ranging from 0.8 to 1.20 litres, most of which were more than five years old. The median riding experience of the riders of the motorcycles was 4 years (range: 5 months to 34 years). Helmet use was very poor as 2-occupant motorcycles compared to 2-occupant motorcycles. Also, 2-occupant motorcyclists were more than seven times more likely to be wearing helmets than >2-occupant motorcyclists. However, riders of 2-occupant motorcycles were 1.8 times less likely to be licensed than riders of >2occupant motorcycles. There was no significant difference in the severity of injuries sustained by persons on 2- and >2-occupant motorcycles. In Table 6, we went further to compare injury and demographic data among patients injured on 2- and >2occupant motorcycle crashes on the basis of their involvement as operators or co-riders. Our aim was to find whether there was a difference in the vulnerability of occupants in these two categories (2 occupants and >2 occupants) when a motorcycle crash occurs. In 2-occupant crash events, the ARR for severe injury in riders
Table 4. Distribution of injuries according to the body regions among riders and co-riders. Body region (N) Head (N D 36) Face (N D 34) Chest (N D 8) Abdomen (N D 2) Extremities (N D 80) External (N D 41)
Rider (% within body region)
Co-rider (% within body region)
p-value
11 (30.5) 17 (50.0) 5 (62.5) 1 (50.0) 25 (31.3) 22 (53.7)
25 (69.5) 17 (50.0) 3 (37.5) 1 (50.0) 55 (68.7) 19 (46.3)
0.098 0.274 0.230 0.820 0.001 0.051
Note: N D total number of patients with injuries to the body region.
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Table 5. Demographic and injury data in crashes involving 2-occupant and >2-occupant motorcycles.
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Attribute
>2-occupant crashes (%)
Injury severity (n D 126) Severe (ISS 16) Mild/moderate (ISS 15) Driver licensing (n D 140) Licensing status Licensed Not licensed Helmet use (n D 162) Yes No Gender Male Female Alcohol Yes No Unknown Speed perception Slow/moderate Fast/very fast Others Mean age Mean ISS Mean RTS
2-occupant crashes (%)
Relative risk (95% CI)
P-value
3 (8.1) 34 (91.9)
4 (4.5) 85 (95.5)
1.8 (0.42 7.67)
0.42
26 (50.0) 26 (50.0)
24 (27.3) 64 (72.7)
1.8 (1.19 2.84)
0.007
1 (1.8) 55 (98.2)
14 (13.2) 92 (86.8)
0.14 (0.02 1.0)
0.05
49 (80.3) 12 (19.7)
109 (90.8) 11 (12.2)
0.045
2 (3.3) 57 (93.4) 2 (3.3)
18 (15.0) 98 (81.7) 4 (3.3)
0.058
19 (31.1) 42 (58.9)
66 (58.9) 47 (40.1)
2-occupants
2-occupants Attribute Crash outcome Sustained injuries Did not sustain injuries Injury severity (n D 126) Severe (ISS 16) Mild/moderate (ISS 15) Helmet use Yes No Others Mean age Mean ISS Mean RTS
Co-rider (n D 60)
Rider (n D 60)
Co-rider (n D 43)
Rider (n D 18)
48 (80.0%) 30 (20.0%)
41(68.3%) 25(31.7%)
.99(0.76 1.28)
25 (58.1%) 18 (41.9)
12 (66.7%) 6 (33.3%)
0.87 (0.58 1.3)
4 (8.3%) 44 (91.7%)
0.0 41 (100%)
a
3 (12.0) 22 (88.0)
0.0 12 (100%)
b
9 (9.4%) 87 (90.6%)
6.0 (9.1%) 60 (90.9%)
c
0.0 40 (100%)
1.0 (6.3%) 15 (93.8%)
d
33.9 8.4e 7.3740
33.7 4.6e 7.7902
23.0 11.6e 7.1726
27.1 3.6e 7.5069
RR (95% CI)
1.03 (0.38 2.75)
RR is undefined as one of the cells has 0 value. ARR is ¡0.083 (CI: ¡0.083 to 0.024). Relative risk is undefined as one of the cells has 0 value. However ARR is ¡0.12 (¡0.012 to 0.0129). c ARR is ¡0.021 (¡0.255 to 0.275). This ARR was calculated to make comparison with the ARR in d easier. d Relative risk is undefined as one of the cells has 0 value. However risk difference is 0.714 (¡0.248 to 0.714). e p < 0.05. a
b
RR
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K.S. Oluwadiya et al.
compared to co-riders was 0.083. That is, if 1000 co-riders in a 2-occupant crash event had been involved as riders, then there would have been 83 less patients with severe injuries. For >2-occupant crash events, the risk reduction was a third more than in 2-occupant crash events (i.e. 120 less patients with severe injuries). The risk reduction of wearing helmet is even more strikingly different between co-riders and riders of 2-occupant and >2-occupant crashes. The ARR in >2-occupant crashes was 0.714, which means that if 1000 co-riders who were involved in the crash event had been involved as riders, then 714 more of the victims would have been wearing helmets. Whereas, for 2-occupant situations, the ARR was ¡0.021, meaning that if 1000 co-riders who were involved in the crash event had been involved as riders, then a further 21 of the victims would NOT have been wearing helmets. Also, of the 16 persons who were wearing helmets when the crashes occurred, 15 (93.4%) of them occurred on 2occupant motorcycles. Discussion Crashes involving motorcycles with multiple occupants accounted for more than 60% of patients injured in motorcycle crashes presenting to the study hospitals. This emphasizes one of the major differences between motorcycle usages in resource-poor settings compared to HICs. In HICs where motorcycles are mostly used for recreational purposes (Hurt, Ouellet, & Thom, 1981), most motorcycle crashes involved single-occupant motorcycles. For example, in the Motorcycle Accidents In Depth Study (MAIDS), only 8.7% of crashed motorcycles were carrying a co-rider (ACEM, 2009). On the other hand, in LMICs, riding motorcycles is a means of living and a necessary part of daily commuting to and from work (Oluwadiya, 2010b). Many are used for commercial commuting and their operators have strong motivations for profit (Oluwadiya et al., 2009), therefore the more coriders they ferry, the greater their profit. This profit motivated drive may be the reason why 23.1% of the motorcycles in this study were carrying more than the two recommended persons (the rider and one co-rider) when the crash occurred. In the MAIDS study, none of the motorcycles involved in the study was carrying more than two occupants (Association for the Advancement of Automotive Medicine, 1998). The injured patients in this study comprised 42.1% riders and 57.9% co-riders. This is contrary to the findings from previous MCI studies in Nigeria, in which riders had always been reported as being more commonly injured than co-riders (Adegbehingbe et al., 2004; Nzegwu, Aligbe, Banjo, Akhiwui, & Nzegwu, 2008; Oginni, Ajike, Obuekwe, & Fasola, 2009; Oluwadiya et al., 2009; Oluwadiya et al., 2004; Solagberu et al., 2006). For example, of all injured patients in the study reported by Solagberu
et al. (2006), 53.6% were riders, 32.1% co-riders, and 14.3% pedestrians, and in the series by Oginni et al. (2009), 62.4% of the injured patients were riders, 25.3% were co-riders, and 12.2% were pedestrians. While these studies showed that overall, riders were injured more than other categories of motorcycle crash victims, it may not be a true reflection of the relative vulnerability of the different categories of motorcycle crash victims to injury. By necessity, all motorcycle crashes must involve a rider, but not all will involve co-riders. Therefore, riders experience more crash events than other categories of road users. For example, all previous studies from Nigeria included single-occupant motorcycle crashes. Our study, on the other hand, focused exclusively on crashes involving motorcycles with multiple occupants. It should serve as a true reflection of risk to riders versus risk to co-riders in such situations. Our study showed that, overall, the risks of sustaining injuries in riders and co-riders are similar. However, when only severe injuries were considered, co-riders had a greater risk of sustaining severe injuries than riders. Reasons for the increased vulnerability of co-riders to sustaining severe injuries might have been because co-riders were less likely to wear helmets. The other probable reason was that riders being in control of the motorcycles were probably more likely than co-riders to be alert, and as a result, be better prepared to brace themselves for crash impacts; and thus, sustain less severe injuries. The number of occupants was the only significant predictor of injury in the logistic regression. Motorcycles are designed in such a way that they handle and perform optimally within certain specifications (ACEM, 2009). With this in mind, motorcycles are designed to perform optimally when carrying one or two persons. Even then, taking on the suggested one passenger may actually increase the risk of crash. For instance, the MAIDS study found that 17.8% of crashes involving motorcycles carrying (one) pillion passengers were cases ‘where the passenger suddenly shifted, causing a control instability in the motorcycle and cases where the passenger had distracted the motorcycle operator, causing an accident’ (ACEM, 2009). The handling dynamics can only be worsened with more than two occupants on the motorcycles. In some cases, extra co-rider(s) were seated on the fuel tank in front of the rider, which may block the rider’s view. In Nigeria, it is illegal for motorcyclists to take more than one co-rider at a time (Federal Road Safety Commission, 1997). Yet this study shows that it is a common occurrence on Nigerian roads as more than one out of every five patients included in the study were injured on motorcycles with three or more occupants. One reason for this risky behaviour may be because the motorcycle riders, who were mostly commercial motorcyclists, were under intense pressures to turn profit (Oluwadiya et al., 2009). The other reason may be age-related. The mean age of
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International Journal of Injury Control and Safety Promotion patients injured on motorcycles with two or more occupants was almost 10 years younger than the mean age of those injured on motorcycles with two occupants. This is in agreement with studies over the world which shows that young road users are more likely to take risky decisions than older road users (Brown & Groeger, 1988; Deery, 1999; Nell, 2002). Why were riders of 2-occupant motorcycles involved in crashes 1.8 times less likely to be licensed compared to riders on >2-occupant motorcycles? This counter-intuitive finding might not be very reliable because the respondents may have lied about the licensing status of motorcycle riders. A previous communitybased study of motorcycle riders from the same region had shown that only 14 riders out of 37 who had previously claimed to have driving licence were able to produce them when asked to do so (Oluwadiya, 2010b). Persons on >2-occupant motorcycles, some of whom were teenagers may have lied to the contrary, either out of fear or to avoid chastisements, when they knew (or were not sure) that the riders of their motorcycles were not licensed. On the other hand, persons on 2-occupant motorcycles, who were on the average, almost a decade older than those on >2-occupant motorcycles may have been more likely to tell the truth when they knew their riders were not licensed. Even though there is a helmet law in place in Nigeria, adherence to the law had been very poor (Oginni et al., 2009; Oluwadiya et al., 2009; Oluwadiya et al., 2004; Solagberu et al., 2006). A subtle cause of this poor adherence is when riders take on more than one co-rider on the motorcycle. The law stipulates that a commercial motorcyclist should have two helmets with him always; one for the rider and the other for the co-rider. In a situation where there were more than two co-riders on the motorcycle, it meant one of the co-riders had to do without a helmet. Additionally, taking on more than the legal one co-rider may be a pointer to other risky behaviours taken by motorcyclists. As extrapolated from our data, only one (1.7%) out of the 59 patients injured on >2-occupant motorcycle crashes was helmeted compared to 16 (13.3%) out of the 120 who were injured in 2-occupant crashes. Second, in contrast to the 2-occupant crashes that occurred, a significantly higher proportion of those injured on >2-occupant crashes occurred while the motorcycle was perceived to have been moving too fast. Because of the increasing popularity of motorcycles for transport, it is likely that the problem of motorcycle injuries will continue to increase in future. Data from the Federal Road Safety Commission, the federal government agency saddled with the responsibility of maintaining road safety in Nigeria showed more than a 10-fold increase in motorcycle registration between 1991 and 1998 (Oyesiku, 2002). Similarly, in 2004, 52% of all motor vehicle licence plates issued in Nigeria were for
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motorcycles (Federal Road Safety Commission, 2006). A recent review of Nigerian literature on trauma over the last four decades showed that motorcycle injuries have increased six times from 6.2% of all RTIs in the 1970s to 36.3% between 2000 and 2009 (Oluwadiya, 2010a). It is therefore important to find ways to reduce the crash rate in order to avoid the anticipated increase in motorcycle injuries. Some studies have shown that the fear of personal injuries can be a powerful incentive to adopting safety practices in driving (Kizer & Trent, 1991; Nell, 2002). Therefore, referencing this study and others like it, and publicizing the fact that motorcycle riders stood a higher risk of sustaining severe injuries in crashes when carrying more than the legal one pillion passenger can be used to encourage them to comply with the law. Furthermore, the results of our study can be used to persuade coriders to avoid overloaded motorcycles. A simple message such as ‘carrying more than one co-rider on a moving motorcycle doubles your risk of sustaining serious injuries’ can be broadcasted by mass media to encourage motorcycle users to be more compliant and consequently reduce the incidence of injuries associated with multioccupant motorcycle crashes. There are few studies of the effectiveness of mass media campaign in reducing road traffic related morbidity and mortality in developing countries and none, to our knowledge, for Nigeria. However, maternal and reproductive health studies have shown that mass media campaigns can produce positive changes or reduce negative health related behaviours among Nigerians (Keating, Meekers, & Adewuyi, 2006; Piotrow et al., 1990). Finally there should be a major improvement in the enforcement of traffic rules and regulations because this has been shown to be the most important way of ensuring safe motoring. Based on the findings in this study, we suggest that law enforcement agents take more interest in preventing >2-occupant motorcycle riding, as this will have the twin benefits of improving helmet use and reducing severe injuries. The limitations of this study stemmed from the fact that it is a hospital-based study of injured motorcyclists. Hospital-based data acquisition commonly excludes onscene deaths and some with mild to moderate injuries. In addition, some patients may have sought treatments at other health care facilities apart from the tertiary health centres where the study took place. Thus it is possible that the incidence of MCIs recorded in this study may be lower than the true population estimate, and the data might have been skewed towards more severe injuries. This effect could have been mitigated by the fact that most victims of road crashes in Nigeria are taken directly to the nearest tertiary health centres. Finally, in the data poor setting of the study, hospital-based studies are commonly the most reliable source of realistic data on injuries and their causes.
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Acknowledgements The authors wish to thank Miss Hauwa Adeniji for assisting in proof reading the manuscript.
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