Helmet Manual

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HelmetsA road safety manual for

decision-makers and

practitioners


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WHO Library Cataloguing-in-Publication Data

World Health Organization.

Helmets : a road saety manual or decision-makers and practitioners.

. Head protective devices utilization . Craniocerebral trauma prevention and control.. Program development methods . Program evaluation methods . Guidelines I. itle

ISBN 2 4 2 4 (NLM classication: WL 34)

Suggested citation:Helmets: a road saety manual or decision-makers and practitioners. Geneva, World HealthOrganization, 2.

World Health Organization 00All rights reserved. Publications o the World Health Organization can be obtained rom WHOPress, World Health Organization, 2 Avenue Appia, 2 Geneva 2, Switzerland (tel: +4 22 324; ax: +4 22 4; e-mail: [email protected]). Requests or permission to reproduceor translate WHO publications whether or sale or or noncommercial distribution should beaddressed to WHO Press, at the above address (ax: +4 22 4; e-mail: [email protected]).

Te designations employed and the presentation o the material in this publication do not imply theexpression o any opinion whatsoever on the part o the World Health Organization concerning thelegal status o any country, territory, city or area or o its authorities, or concerning the delimitation oits rontiers or boundaries. Dotted lines on maps represent approximate border lines or which theremay not yet be ull agreement.

Te mention o specic companies or o certain manuacturers products does not imply that theyare endorsed or recommended by the World Health Organization in preerence to others o a similarnature that are not mentioned. Errors and omissions excepted, the names o proprietary products aredistinguished by initial capital letters.

All reasonable precautions have been taken by the World Health Organization to veriy the inor-mation contained in this publication. However, the published material is being distributed withoutwarranty o any kind, either express or implied. Te responsibility or the interpretation and use o thematerial lies with the reader. In no event shall the World Health Organization be liable or damagesarising rom its use.

Design by Inswww.inis.ie

Illustrations by Shaun Smith

Printed in Switzerland


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Table of contents

Preface vii

Contributors and acknowledgements ix

Executive summary xi

Introduction xiii

Background to the series of manuals xiii

Background to the helmet manual xv

1. Why are helmets needed? 1

11 Many people around the world die in motorcycle collisions 3111 Head injuries are a leading cause of death and disability 4

12 A helmet protects your head 7

121 The mechanism of head injuries 7

122 How a helmet works 9

123 Motorcycle helmet design 11

13 Helmet use is effective at reducing head injuries 14

14 Helmet programmes are effective at getting helmets on heads 18

Summary 22

References 23

2. How to assess the situation in your country 25

21 Why do you need to assess the situation? 27

211 The quality of the data 28

22 How widespread is the problem of non-use of helmets? 29

221 How big is the motorcycle injury problem? 29

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iv

222 What is the helmet-wearing rate in the area being considered? 35

223 Why dont people wear helmets? 41

23 How to assess what is already in place 44

231 Who is in charge of road safety, and what funds are there for it? 45

232 Who are the stakeholders? 45

233 Is there a helmet use law in place? 47

234 Is there a helmet standard in place? 47

235 Have any helmet programmes been attempted so far? 48

236 Using the situational assessment to prioritise actions 51

Summary 51

References 52

3. How to design and implement a helmet programme 53

31 Establishing a working group 57

311 Who to involve? 57

312 Assigning roles to working group members 59

32 How to prepare a plan of action 61

321 Setting the programmes objectives 61322 Setting targets 63

323 Setting performance indicators 66

324 Deciding on activities 68

325 Setting a timeframe 69

326 Estimating resource needs 69

327 Setting up a monitoring mechanism 71

328 Ensuring sustainability of the programme 72

33 How to develop and implement a helmet law 75

331 Developing the law 75332 Introducing and implementing legislation 77

333 Developing a timeframe for implementation of a law 82

34 How to design and implement a helmet standard 83

341 Adopting a standard 83

342 Key considerations when setting standards 85

343 General specications for helmets 87

35 How to improve compliance with the law 93

351 Voluntary measures to increase helmet use 94

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v

352 Compulsory measures to increase helmet use 96

36 How to involve the public 103361 Selecting an agency for the campaign 103

362 Objectives of the campaign 103

363 Changing knowledge and attitudes on helmet use 104

364 Working with the media 104

365 Creating campaign messages 106

366 Setting a campaign schedule 107

367 Carrying out and evaluating the campaign 108

37 Educating young people 111

38 Ensuring an appropriate medical response 115

Summary 119

References 122

4. How to evaluate the programme 123

41 Planning the evaluation 125

411 Aims of evaluation 126

412 Types of evaluation 126

42 Choosing the evaluation methods 127

421 Study types for formative and process evaluations 128

422 Study types for impact and outcome evaluations 128

423 Choosing the performance indicators 132

424 Conducting an economic evaluation of a programme 133

425 Determining sample size 135

43 Dissemination and feedback 136

Summary 138

References 138

Glossary of terms 141

Partner organiations in the development of the manual 145


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Preface

Road trac injuries are a major public health problem and a leading cause o deathand injury around the world. Each year nearly .2 million people die and millionsmore are injured or disabled as a result o road crashes, mostly in low-income andmiddle-income countries. As well as creating enormous social costs or individu-als, amilies and communities, road trac injuries place a heavy burden on healthservices and economies. Te cost to countries, possibly already struggling with otherdevelopment concerns, may well be %2% o their gross national product. As

motorization increases, road trac crashes are becoming a ast-growing problem,particularly in developing countries. I present trends continue unchecked, roadtrac injuries will increase dramatically in most parts o the world over the next twodecades, with the greatest impact alling on the most vulnerable citizens.

Appropriate and targeted action is needed most urgently. Te World report on roadtrac injury prevention, launched jointly in 24 by the World Health Organizationand the World Bank, identied improvements in road saety management togetherwith specic actions that have led to dramatic decreases in road trac deaths andinjuries in industrialized countries that have been active in road saety. Te use o seat-belts, helmets and child restraints, the report showed, have saved thousands o lives.Te introduction o speed limits, the creation o saer inrastructure, the enorce-ment o blood alcohol content limits and improvements in vehicle saety, are allinterventions that have been tested and repeatedly shown to be eective.

Te international community must now take the lead encouraging good practice inroad saety management and the take up o these interventions in other countries,in ways appropriate to their particular settings. o speed up such eorts, the UnitedNations General Assembly passed a resolution on 4 April 24 urging greater atten-tion and resources to be directed towards the global road saety crisis. Resolution/2 on Improving global road saety stressed the importance o international

collaboration in the eld o road saety. A urther resolution (A/L.), passed inOctober 2, rearmed the United Nations commitment to this issue, encourag-ing Member States to implement the recommendations o the World report on roadtrac injury prevention, and commending collaborative road saety initiatives so arundertaken towards implementing resolution /2. In particular, it encouragedMember States to ocus on addressing key risk actors, and to establish lead agenciesor road saety.

o contribute to the implementation o these resolutions, the World Health Organi-zation, the Global Road Saety Partnership, the FIA Foundation or the Automobileand Society, and the World Bank, have collaborated to produce a series o manuals

aimed at policy-makers and practitioners. Tis manual is one o them. Each provides


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step-by-step guidance to countries wishing to improve road saety organisation andto implement the specic road saety interventions outlined in the World report onroad trac injury prevention. Tey propose simple, eective and cost-eective solu-tions that can save many lives and reduce the shocking burden o road trac crashesaround the world. We would encourage all to use these manuals.

E KDirectorDepartment o Injuries and Violence PreventionWorld Health Organization

D ScckChie ExecutiveGlobal Road Saety Partnership

D WDirector GeneralFIA Foundation or the Automobile and Society

A BLead Road Saety Specialist

ransport and Urban Development DepartmentWorld Bank

Preface

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Contributors and acknowledgements

Advisory Committee

Anthony Bliss, Etienne Krug, David Silcock, David Ward.

Editorial Committee

ami oroyan, Margie Peden, Andrew Downing, Rita Cuypers.

Contributors to Modules and Boxes

Abdulbari Bener, Eric Bernes, Daniel Brod, Witaya Chadbunchachai, Greig Cra,Atze Dijkstra, Do u Anh, Do Hong Anh, Brian Fabian, Charles Goldenbeld,Paul Graham, Jagadish Guria, G. Gururaj, Maria-Isabel Gutirrez, Philip Graitcer,Peter Halldin, Yvette Holder, Jaar Hussain, Rebecca Ivers, Stephen Jan, RichardMatzopoulos, ejdeep Kaur Menon, Margaret Knudson, Charles Mock, Ali Moghisi,Robyn Norton, Krishnan Rajam, Frederick Rivara, Chamaiparn Santikarn, FrancoServadei, Gyanendra Sharma, Aziz Sheikh, Ray Shuey, David Sleet, ChristopherSmith, errance Smith, Elizabeth owner, Radin Umar, Hans van Holst, Hung Dang

Viet, Lynn Vermaak.

Peer reviewers

Shanthi Ameratunga, Eric Bernes, Chris Baguley, Christine Branche, FrancesBunn, Jos Capel Ferrer, Witaya Chadbunchachai, Ann Dellinger, Kathleen Elsig,Vronique Feypell, Laurie Flaherty, Philip Graitcer, G. Gururaj, Sharma Gyanendra,Rebecca Ivers, Meleckidzedeck Khayesi, Robert Klein, Angela Lee, Charles Mock,Jonathon Passmore, Marie-Nolle Poirier, Krishnan Rajam, Eugnia Rodrguez,Mark Rosenberg, Gyanendra Sharma, David Sleet, Christopher Smith, Robert

omlins, Maria Vegega, John White, Diane Wigle, Dee Williams.

Technical editing

ony Kahane.

Administrative support

Pascale Lanvers-Casasola, Marijke Bollaert.


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Financial support

Te World Health Organization wishes to thank the ollowing or their generousnancial support or the development and publication o this manual: the FIAFoundation or the Automobile and Society, the Swedish International Develop-ment Agency, the United States National Highway rac Saety Administration,the United States Centers or Disease Control and Prevention.

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Contributors and acknowledgements


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Executive summary

Along with a global increase in motorization, particularly in low-income and middle-income countries, the use o motorized two-wheelers and bicycles is growing rapidlyin many places. As a result, there are increasing atalities and injuries among userso two-wheelers, with head injuries being a major concern. Motorcycle and bicyclehelmets are eective both in preventing head injuries and in reducing the severity oinjuries sustained by riders and passengers o two-wheelers.

Unortunately, in many countries the use o helmets is low. Te World Report onRoad rac Injury Prevention described how wearing helmets would save many lives.Consequently, the Report recommended that countries set and enorce helmet lawsor drivers and passengers o both motorized two-wheelers and bicycles.

Te purpose o this manual is to provide advice on how to increase the use o helmetswithin a country. Te manual is aimed at policy-makers and road saety practition-ers and draws on experience rom countries that have succeeded in achieving andsustaining high levels o helmet use. It provides the necessary evidence that will beneeded to start a helmet use programme, and takes the user through the steps neededto assess the helmet situation in a country. It then explains the steps needed to design

and implement a helmet use programme, including: setting up a working group;developing an action plan; introducing and enorcing mandatory helmet laws; creat-ing appropriate standards or helmet production; eectively marketing helmets tothe public; educating children and young people on helmet use; and considerationo the capacity or an appropriate medical response to be provided ollowing a crash.Finally, the last section in the manual guides the user on planning and implement-ing an evaluation o the programme, such that results are ed back into programmedesign. For each o these activities, the document outlines in a practical way the vari-ous steps that need to be taken.

In developing the material or this manual, the writers have drawn on case stud-

ies rom around the world to illustrate examples o good practice. Although themanual is aimed at countries with low use o helmets, the modular structure o themanual means it can be used in countries with very dierent levels o helmet use.Te ocus o the manual is on motorcycle helmets, although examples that pertain tobicycle helmet use are also addressed.


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Executive summary


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iIntroduction


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Introduction

Background to the series of manuals

In 24 the World Health Organization dedicated World Health Day to the topic oroad saety. Events marking the day were held in over 3 countries to raise aware-ness about road trac injuries, stimulate new road saety programmes and improveexisting initiatives. On the same day, the World Health Organization and the WorldBank jointly launched the World report on road trac injury prevention, highlight-ing the increasing epidemic o road trac injuries. Te report discusses in detail the

undamental concepts o road trac injury prevention, the impact o road tracinjuries, the main causes and risk actors or road trac crashes, and proven andeective intervention strategies. It concludes with six important recommendationsthat countries can take to improve their road saety record.

Recommendations of the World report on road trafc injury prevention

Identify a lead agency in government to guide the national road trafc

safety effort

Assess the problem, policies, institutional settings and capacity relating to

road trafc injury

Prepare a national road safety strategy and plan of action

Allocate nancial and human resources to address the problem

Implement specic actions to prevent road trafc crashes, minimize injuries

and their consequences and evaluate the impact of these actions

Support the development of national capacity and international cooperation

1

2

3

4

5

6

Te report emphasises that the growing global problem can be averted withimproved road saety organization and system-wide, multi-sectoral implementationo demonstrably eective interventions which are culturally appropriate and testedlocally. In its h recommendation, the report makes it clear that there are severalgood practice interventions already tried and tested that can be implemented atlow cost in most countries. Tese include strategies and measures that address someo the major risk actors or road trac injuries, such as:


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setting laws requiring seat-belts and child restraints or all occupants o motorvehicles;requiring riders o motorcycles to wear helmets;establishing and enorcing blood alcohol concentration limits;setting and enorcing speed limits;managing existing physical road inrastructure in a way as to increase saety;improving vehicle saety.

A week aer World Health Day, on 4 April 24, the United Nations GeneralAssembly adopted a resolution calling or greater attention and resources to bedirected towards road saety eorts. Te resolution recognized that the UnitedNations system should support eorts to tackle the global road saety crisis. At the

same time, it commended WHO and the World Bank or their initiative in launch-ing the World report on road trac injury prevention. It also invited the World HealthOrganization, working in close cooperation with the United Nations RegionalCommissions, to act as coordinator on road saety issues within the United Nationssystem.

Following the mandate conerred on it by the United Nations General Assembly,since the end o 24 WHO has helped develop a network o United Nationsand other international road saety organizations now reerred to as the UnitedNations Road Saety Collaboration. Te members o this group have agreed oncommon goals or their collective eorts, and are initially ocusing attention on the

six recommendations o the World report on road trac injury prevention.A direct outcome o this collaboration has been the setting up o an inormal consor-tium consisting o WHO, the World Bank, the FIA Foundation or the Automobileand Society and the Global Road Saety Partnership. Tis consortium is working toproduce o a series o good practice manuals covering the key issues identied inthe World report on road trac injury prevention. Te project arose out o the numer-ous requests to WHO and the World Bank rom road saety practitioners around theworld asking or guidance in implementing the reports recommendations.

Te manuals are aimed at governments, nongovernmental organizations and road

saety practitioners in the broadest sense. Written in an accessible manner, theyprovide practical steps on how to implement each recommendation in a way identi-ed with good practice, while also making clear the roles and responsibilities o allthose involved. Te manuals are based on a common template that was used in asimilar document on increasing seat-belt use, developed by the FIA Foundation in24. Although primarily intended or low-income and middle-income countries,the manuals are applicable to a range o countries and adaptable to dierent levels oroad saety perormance. Each manual includes case studies highlighting examplesrom both developed and developing countries.

Te World report on road trac prevention advocates a systems approach to road

saety one that addresses the road, the vehicle and the user. Its starting point is that

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to eectively tackle road trac injuries, responsibility needs to be shared betweengovernments, industry, nongovernmental organizations and international agencies.Furthermore, to be eective, road saety must have commitment and input rom allthe relevant sectors, including those o transport, health, education and law enorce-ment. Tese manuals refect the views o the report; they too advocate a systemsapproach and ollowing the principle that road saety should be pursued acrossmany disciplines they are targeted at practitioners rom a range o sectors.

Background to the helmet manual

Why was the helmet manual developed?

Many countries around the world are acing the problem o a rapidly rising numbero people injured or killed while riding two-wheelers motorcycles and bicycles. Alarge proportion o the deaths and severe injuries result rom injuries to the head.Helmets are eective in reducing the likelihood o head injuries, as well as theirseverity. Increasing helmet use in a country is thus an important way o improvingroad saety.

Tis manual seeks to provide practical advice to road saety practitioners on how toachieve a much higher proportion o users o two-wheeled vehicles wearing helmets.It ollows on rom the World report on road trac injury prevention, which described

evidence that setting and enorcing mandatory helmet use was an eective interven-tion or reducing injuries and atalities among two-wheeler users. As already men-tioned, the manual is one o a series o documents providing, in an accessible orm,practical advice to countries on the steps necessary or improving their overall roadsaety record.

Who is the manual or?

Te manual is or use in countries that want to improve the rates o helmets useamong users o two-wheelers, nationally or at a local level. It is targeted at govern-ments, nongovernmental organizations and road saety practitioners. Te list o

possible users will vary according to the country and its current situation with regardto helmet use, but will certainly include:

policy-makers and decision-makers;members o the judiciary;politicians;police ocers;road saety and public health proessionals;transport managers;manuacturers o motorcycles and bicycles;helmet manuacturers

employers in the public and private sectors;


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nongovernmental organizations;insurance industry personnel;school and college teachers;researchers on road saety;instructors in driving and road saety.

Te manual provides practical steps mainly on increasing helmet use among motor-cycle users, though it also highlights case studies which illustrate issues aroundbicycle helmet use. Although aimed particularly at low-income and middle-incomecountries with low levels o helmet use, it is intended to be useul or all countries.

What does this manual cover and how should it be used?

Increasing the rate o helmet use requires a number o steps. Exactly how many stepsare needed will depend on how much is already in place in a particular country in theway o helmet programmes. Tis manual helps users identiy which steps are relevantto their situation, and then provides the practical advice needed to implement thesteps. As well as ocusing strongly on technical measures, the manual also describesthe institutional structures that need to be in place or a helmet programme to besuccessul.

As explained in Module o this manual, the burden o deaths and injuries amongusers o two-wheelers is predominantly in low-income and middle-income countries.For this reason, the manual draws considerably on experience rom such countries,with the intention that the content will be most relevant to other countries with asimilarly high burden o injuries among two-wheeler users. Nonetheless, the struc-ture o the manual is such that it can be applied to a wide range o countries in termso their economies and levels o helmet use.

What is covered?

Te manual ocuses primarily on motorcycle helmets, since rom a global perspectiveit is motorcycle users who suer the majority o injuries and atalities among two-wheeler users. However, it also addresses bicycle helmets. In order, though, to mini-

mize the duplication that would result rom addressing each issue rst or motorcyclehelmets and then or bicycle helmets, the main steps are discussed predominantlywith reerence to motorcycle helmets.

Tere are some controversial issues related to both motorcycle and bicycle helmet useand the manual addresses these. ackling such issues will certainly increase the suc-cess o policies aimed at cutting the rate o injuries among motorcyclists and cyclists.

Te technical content o this manual is divided into our modules, structured asollows.

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Module 1 explainswhy interventions are needed to increase helmet use. Itdescribes how helmets protect wearers and how eective they are in reducing headinjuries.Module 2 guides the user through the process oassessing a countrys situationon helmet use. It outlines the data needed or a good diagnosis, and how thesedata can be used to set realistic targets and priorities or a programme.Module 3 is about designing and implementing a helmet programme, includinghow to develop an action plan, including setting objectives, and deciding on activi-ties needed to meet these objectives, estimating resources and setting a timerame.Te module includes sections on developing legislation and standards on helmetuse, improving compliance, and establishing appropriate marketing and publicitystrategies. Educational interventions are also discussed, as well as the need to con-

sider the capacity to respond appropriately when motorcycle crashes do occur.Module 4 is about evaluation o a helmet programme. Tis includes identiyingthe aims o the evaluation, considering dierent types o evaluation and choosingthe most appropriate methods, and choosing the perormance indicators to beused. Te module also discusses the need to disseminate the evaluation results anduse them to improve the programme.

Case studies, in the orm o boxed text, are included throughout the manual. Teseexamples have been chosen to illustrate processes and outcomes, with experiencesrom a wide range o countries, refecting regional, cultural and socioeconomic diver-sity. Less detailed notes are also included as boxed text to illustrate brieer points ointerest.

How should the manual be used?

Te manual is not intended to be prescriptive, but rather adaptable to particular needs.

Te technical modules contains fowcharts and checklists to help readers determinewhere their country stands with regard to helmet use, and to take those steps oer-ing the greatest potential or improvement. Te modular structure o the manual isintended to help this process o using only the relevant parts o the document.

Although it would help everyone to read the whole document, it is envisaged thatparticular sections will meet the needs o dierent countries. Nonetheless, all userswill probably benet rom reading Module 2, enabling them to assess their situa-tion and to pick particular actions to undertake. Te choices made at this point willdecide which o the remaining sections are useul. For example, a country where useo two-wheelers is high but lacking a helmet law and helmet standard might useullywork through all the technical sections. On the other hand, a country with an exist-ing helmet law and helmet standard, an eective public awareness campaign aroundhelmet use, but without monitoring or evaluation procedures, may choose primarilyto use Module 4, while reading the other modules only or reerence.


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We encourage users to adapt the manual to local conditions: this means it may needto be translated and that sections o it may need to be altered to suit the local envi-ronment. We would also appreciate eedback on users experiences in this process.

What are the manuals limitations?

Tis manual is not meant to be comprehensive. It draws upon the experience o itscontributors rom around the world to identiy practical and eective steps that canbe taken on helmet use, and thus refects the views o those involved in its produc-tion. Tere may well be successul interventions ollowed by other countries thatare not addressed here. Similarly, the case studies used to illustrate processes, goodpractice and practical constraints are not exhaustive but merely illustrate points

made in the main text.While the manual ocuses on helmet use among motorcyclists, it also addressescyclists. However, where the steps involved in a process are the same or both motor-cycle and bicycle helmet use, they are presented only or motorcycle helmet use, toavoid repetition.

Te manual is not an academic document. Te reerences contained are only tomaterial used in its development, and there is no attempt at an exhaustive literaturereview.

How was the manual developed?Te manual was based on a standard template that was developed jointly by the ourpartner organizations (the World Health Organization, the World Bank, the FIAFoundation or the Automobile and Society, and the Global Road Saety Partner-ship), and reviewed externally. Te template was not meant to be rigid, but to pro-vide a loose structure which, where possible, would uniy the manuals in their ormand approach.

An advisory committee o experts rom the dierent partner organizations oversawthe process o developing each manual, and to provide guidance on its content. Asmall editorial committee or each manual then coordinated its technical content.

An outline o this manual on helmet use was produced by WHO as the projectleader, and sent to the advisory and editorial committees or comment. echnicalmodules o the document were contracted out to organizations or individuals withparticular expertise in an area. Tese people urther developed the outline o theirmodules, reviewed the relevant literature and wrote the technical content, ensuring itrefected the latest scientic views on good practice.

Te technical modules were reviewed independently by road saety practitioners,researchers and other experts rom around the world. Te document was then sentor technical editing.

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Dissemination o the manual

Te manual is being translated into a number o languages, and countries are encour-aged to translate the document into local languages. Te manual will be disseminatedwidely through the distribution network used or the World report on road tracinjury prevention. Te our partner organizations involved in the manual will plantraining workshops to accompany in-country launches o the manual.

Te manual will also be available in PDF ormat to be downloaded ree rom the websites o all our partner organizations (see page 4).

Tis helmet manual is downloadable romwww.who.int/violence_injury_prevention/publications/road_trac/en/index.html

How to get more copies

Further copies o the manual can be ordered by writing to:

Department o Injuries and Violence Prevention,World Health Organization2 Avenue Appia, CH-2Geneva 2, Switzerland

Or by e-mailing: [email protected]


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Why are helmets needed?

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Why are helmets needed?

1.1Manypeoplearoundtheworlddieinmotorcycle

collisions. 3

111.Head.injuries.are.a.leading.cause.o.death.and.disability. 4

1.2Ahelmetprotectsyourhead . 7

121. The.mechanism.o.head.injuries. 7122. How.a.helmet.works. 9

123. Motorcycle.helmet.design. 11

1.3Helmetuseiseffectiveatreducingheadinjuries. 14

1.4Helmetprogrammesareeffectiveatgettinghelmetsonheads. 18

Summary. 22

References . 23


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Why

arehelmetsneeded?

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This moduleprovidesthe user with background material on why helmets areneeded. Such inormation is important in persuading political leaders and the

public to support a helmet programme.

Te sections in this module are structured as ollows:

. Many people around the world die in motorcycle collisions: Te modulebegins by describing the magnitude o the problem o motorcycle crashes, andresulting head injuries. It explains the global distribution o the problem, notingthat i present trends continue, many low-income and middle-income countriesare likely to experience an increase in the number o motorcycle crashes in the near

uture. Te section describes how head injuries that result rom motorcycle colli-sions are a leading cause o death and disability..2 A helmet protects your head: Tis section describes what can happen to thehead in the event o a motorcycle or bicycle collision. It then goes on to explainthe physical components o a helmet and the way in which they reduce the impacto a collision. Tis section also describes how helmets are designed to meet certainrequirements.. Helmet use is eective at reducing head injuries: Tis section summarizesthe evidence rom studies that have evaluated the eectiveness o helmets in reduc-ing death and injury.. Helmet programmes are eective at getting helmets on heads: Introduc-ing legislation on helmet use has been shown to be eective in increasing helmet-wearing rates and reducing head injuries, as summarized in this section.

As mentioned in the Introduction, this manual is ocused on how to increase helmetuse among motorcycle users. Te increasing use o motorized two-wheelers, and thehigh speed at which motorcycles can travel compared to bicycles, means that theprimary audience o this manual will be those seeking to increase motorcycle helmetuse. Nonetheless, it is assumed that much o the technical guidance that is providedin the text will be equally relevant, and can be applied easily, to those seeking tointroduce a helmet programme or bicycle users.

1.1 Many people around the world die in motorcycle collisions

Road trac injuries are a major public health problem and a leading cause o deathand injury around the world. Each year nearly .2 million people die as a result oroad crashes, and millions more are injured or disabled (1). In many low-income andmiddle-income countries, where motorcycles and bicycles are an increasingly com-

mon means o transport, users o two-wheelers make up a large proportion o those


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Module 1: Why are helmets needed?

4

injured or killed on the roads. Motorcycle and bicycle riders are at an increased risko being involved in a crash. Tis is because they oen share the trac space withast-moving cars, buses and trucks, and also because they are less visible. In addition,their lack o physical protection makes them particularly vulnerable to being injuredi they are involved in a collision.

In most high-income countries, motorcycle atalities typically comprise around 5%to 1% o overall trac atalities (2,3). Tis proportion refects the combined eecto several important actors including the relatively low ownership and use o motor-cycles in many developed countries, and the relatively high risk o these motorcyclesbeing involved in crashes involving atalities. ypically, these risks are much higheror motorcycle than or vehicle travel (4).

In low-income and middle-income countries, car ownership and use rates are gener-ally much lower than in high-income countries. However, the ownership and useo motorcycles and other two-wheelers is generally relatively high or example,in India % o the total number o motor vehicles are motorized two-wheelers,considerably higher than in high-income countries (3). Refecting this dierence, thelevels o motorcycle rider atalities as a proportion o those injured on the roads aretypically higher in low-income and middle-income countries than in high-incomecountries (Figure .). For instance, 2% o road deaths in India are among userso motorized two-wheelers, while this gure is between % in Tailand, andabout % in Malaysia (3,5,6). In China, motorcycle ownership between and

2 grew rapidly rom 23% to 3%, with a corresponding increase in the proportiono trac atalities sustained by motorcyclists rising rom .% to % over the sameperiod (7). However, in other low-income and middle-income countries, a lack ohigh quality road saety data means that precise levels o motorcycle rider atalitiesare still not known.

1.1.1 Head injuries are a leading cause of death and disability

Injuries to the head and neck are the main cause o death, severe injury and disabil-ity among users o motorcycles and bicycles. In European countries, head injuries

contribute to around % o deaths among motorized two-wheeler users; in somelow-income and middle-income countries head injuries are estimated to account orup to % o such atalities (6,8). Te social costs o head injuries or survivors, theiramilies and communities are high, in part because they requently require special-ized or long term care. Head injuries also result in much higher medical costs thanany other type o injury (9), such that these injuries exert a high toll on a countryshealth care costs and its economy.

Globally, there is an upward trend in the number and use o motorcycles and bicy-cles, both or transport and recreational purposes. Indeed, most o the growth inthe number o vehicles on the worlds roads comes rom an increasing use o motor-

ized two-wheelers. Asian countries, in particular, are expected to experience a


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considerable rise in the numbero motorized two-wheelervehicles on their roads. Tisrapid growth in the use omotorcycles in many low-income and middle-incomecountries is already beingaccompanied by a consider-able increase in the number ohead injuries and atalities thatwill only continue to increasei present trends continue

unchecked.

Figure 1.1 Road users killed in various modes of transportas a proportion of all road trafc deaths

Adapted from reference 1

H

JSomme

r,GTZ,

2003

Helmet programmes will be important to policy-makers in Africa, where there is

an increasing use of motorized two-wheelers.


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6

Satien Luangpitak, 28, is a motorcycle taxi driver

in northern Bangkok As in much of urban Thailand,

motorcycle taxis are a common means of personal

transport However, despite a national mandatory

helmet law for taxis and passengers, enforcement

is sporadic and it is common to see unhelmeted

drivers and passengers

In May 2004 Satien was involved in a crash while

driving in heavy trafc As he tried to overtake a

car, he collided with another motorcycle taxi in

front of him Satien was travelling at 80 km/h and,upon impact, was thrown forward and landed on

the pavement, striking his helmeted head and his

left shoulder He lost consciousness for about half

an hour Another motorcycle taxi driver stopped to

assist him: rather than call and wait for the emer-

gency services, this man lifted Satien and removed

him from the roadway He then moved him to a

vehicle and evacuated him to a hospital an action

meant in good faith, but that he later learnt may

have inicted a spinal cord injury on Satien

At hospital, Satien received treatment for trauma to

his head and shoulder He was discharged from thehospital after six hours with a neck brace and partial

body brace He received follow-up treatments and

was able to return to a full work schedule a month

later Aside from the initial loss of consciousness,

in the two years since his crash, he has suffered

no ill effects from the trauma to his head While

his injured shoulder has regained 100 percent

functionality, he still experiences pain in his neck

and shoulder when lifting heavy objects with his

left arm

When interviewed, Satien pointed out that at no time

did anyone, including the medical staff speciallytrained to deal with motorcycle crash victims, advise

him to replace his helmet after the crash Crash

helmets offer little or no protection after having

absorbed the impact of a crash

Fortunately, all of Satiens medical costs were

covered by Thailands mandatory third-party liability

insurance coverage However, he incurred costs

in repairing his motorcycle (15 000 baht, about

US$ 390), and as a result of his lost income during

his recovery period, which he estimates at 10 000

baht (US$ 260)

The crash has also had an emotional impact: Satien

constantly worries that he may eventually suffer a

debilitating injury from a crash, is fearful of driving

at higher speeds in trafc, and has become increas-

ingly uneasy when his passengers refuse to wear a

helmet His experience has also altered his behav-

iour with regard to helmet use: prior to the crash, headmits he was inconsistent about using his helmet

in areas where he knew enforcement was unlikely,

but that now he wears a helmet at all times He also

explains that since the crash, he has taken out dis-

ability insurance

BOX 11: The story behind the helmet

Satien explains that his experience has increased his awareness

of the need to wear a helmet consistently.

Source: In May 2006 Satien Luangpitak was interviewed

by Daniel Brod, ASIRT


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1.2 A helmet protects your head

Te technical expertise behind the design o high quality helmets is based on anunderstanding o what happens to the head in the event o a motorcycle crash. Tissection describes what happens in the event o a motorcycle crash, and then explainshow a helmet works to reduce this eect.

1.2.1 The mechanism of head injuries

An appreciation o the anatomy o the head is important in understanding the mech-anism o injuries to the head and brain (Figure .2). Briefy, the important anatomicalinormation about the head to note is the ollowing:

Te brain is enclosed within a rigid skull.Te brain sits on bones that make up the base o the skull.Te spinal cord passes through a hole in the underside o the brain.Under the skull, adhering to the bones, is a tough tissue called the dura that sur-rounds the brain.Between the brain and the dura is a space containing cerebrospinal fuid that pro-tects the brain tissue rom mechanical shock.Te brain foats in the cerebrospinal fuid but it can only move about millimetre in any direction.

Te skull is covered by the scalp, which provides some additional protection.

Figure 1.2 Structure of the head and brain

Skin

Bone/skull

Brain

Cerebrospinaluid

Dura mater

Epidural space


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8

During a motorcycle or bicycle crash there are two principal mechanisms o injuryto the brain: through direct contact and through accelerationdeceleration. Eachmechanism causes dierent types o injuries.

When a motorcycle or bicycle is involved in a collision, the rider is oen thrownrom the cycle. I the riders head hits an object, such as the ground, the headsorward motion is stopped, but the brain, having its own mass, continues to moveorward until it strikes the inside o the skull. It then rebounds, striking the oppositeside o the skull. Tis type o injury can result in anything rom a minor head injury,such as concussion, to a atal head injury.

Head injuries that result rom either contact or accelerationdeceleration injuries arethemselves divided into two categories: open or closed head injuries. Most traumatic

brain injuries are the result o closed head injuries that is, there is no open woundto the brain. Figure .3 describes the two broad types o head injuries and gives exam-ples o the types o lesions in each category rom the mildest to the most severe.

Figure 1.3 Types of head injuries

Closed

Do not penetrate the bonesof the skull Occur as aresult of an impact whichjars the brain in the skullMovement of the brainwithin the skull may resultin bruising, swelling, tearingof the brain tissues, nervesor blood vessels

Open

Involve a fracture orpenetration of theskull May result inbrain injuries

Examples

Different typesof open skullfractures

Penetratinginjuries

Examples

Concussion (injury wherethere is no bleeding, mayor may not involve losingconsciousness)

Brain contusions (damageto the nerves or bloodvessels)

Intracranial haemorrhagesin different areas of thebrain

HEAD INJURIES


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Motorcycle riders who do not wear a helmet run a much higher risk o sustaining anyo these head and traumatic brain injuries, or a combination o them. Helmets createan additional layer or the head and thus protect the wearer rom some o the moresevere orms o traumatic brain injury.

1.2.2 How a helmet works

A helmet aims to reduce the risk o serious head and brain injuries by reducing theimpact o a orce or collision to the head.

A helmet works in three ways:It reduces the deceleration o the skull, and hence the brain movement, by manag-

ing the impact. Te so material incorporated in the helmet absorbs some o theimpact and thereore the head comes to a halt more slowly. Tis means that thebrain does not hit the skull with such great orce.It spreads the orces o the impact over a greater surace area so that they are notconcentrated on particular areas o the skull.It prevents direct contact between the skull and the impacting object by acting as amechanical barrier between the head and the object.

Tese three unctions are achieved by combining the properties o our basic compo-nents o the helmet that are described below (Figure .4).

Figure 1.4 Components of a helmet

Rigid outer shell

Impact-absorbing liner

Comfort/t padding

Face shield

Retention system


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Te shell

Tis is the strong outer surace o the helmet that distributes the impact over a largesurace area, and thereore lessens the orce beore it reaches the head. Although theshell is tough, it is designed to compress when it hits anything hard. It provides pro-tection against penetration by small, sharp and high speed objects and it also protectsthe padding inside the helmet rom abrasions and knocks during daily use. Teserequirements mean that the shell must be hard, usually with a smooth exterior nish.

Te impact-absorbing liner

Tis is made o a so, crushable padded material usually expanded polystyrene,commonly called styrooam. Tis dense layer cushions and absorbs the shock as the

helmet stops and the head tries to continue moving.

Te comort padding

Tis is the so oam-and-cloth layer that sits next to the head. It helps keep the headcomortable and the helmet tting snugly.

Te retention system, or chin strap

Tis is the mechanism that keeps the helmet on the head in a crash. A strap is con-nected to each side o the shell. Chin and neck straps, which are specically designed

to keep the helmet on during an impact, must be correctly used or the helmet tounction as it is designed to (see box below).

Using helmets properly

A study in Malaysia examined the

compliance of helmet use in a typical

Malaysian town Of the 5000 motorcy-

clists studied, only 54% used helmets

properly, 21% used them improperly,

and 24% did not wear them at all

Younger people, men and those with

less formal education were more likely

to not wear helmets properly (10).

Many helmet users do not secure their helmets

properly and sometimes not at all thereby

rendering the helmet of little if any value in

the event of a collision


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1.2.3 Motorcycle helmet design

In addition to meeting the previously described unctions and conorming to stand-ards (to be discussed in Module 3), a helmet needs to be designed to suit the localweather and trac conditions. Te ollowing are some o the considerations usually

addressed by helmet designers:Materials used in the construction o a helmet should not degrade over time, orthrough exposure to weather, nor should they be toxic or cause allergic reactions.Currently, the plastic materials commonly used are Expanded Poly-Styrene (EPS),Acrylonitrile Butadiene Styrene (ABS), Poly Carbon (PC) and Poly Propylene(PP). While the material o the helmet shell generally contains PC, PVC, ABS orbre glass, the crushable liner inside the shell is oen made out o EPS a materialthat can absorb shock and impact and is relatively inexpensive. However, helmetswith EPS liners should be discarded aer a crash, and in any case users shouldreplace such helmets aer 3 years o use.Standards oen set the minimum coverage o a helmet (see Module 3). Hal-headhelmets oer minimal coverage. Full-ace helmets should ensure that the wearersperipheral vision and hearing are not compromised.o ensure that a helmet can absorb the shock o a crash, the crushable liner shouldbe between . cm and 3. cm in thickness.

What helmets dontdo

Helmets are designed to reduce the chances ofhd, brin, nd cil injuris

occurring, but are not designed to prevent injuries to other parts of the body To

reduce the likelihood of injuries to other parts of the body, the following strate-

gies can be employed:

Appropriate clothing can be helpful to reduce other types of injuries (for exam-

ple, jacket and trousers of particular materials which cover arms and legs

completely; sturdy shoes or boots; gloves which give a better grip and protect

the hands in the event of a crash)

Obeying the laws of the road, including adhering to speed limits and not driving

while drunk are behaviours that will reduce the chance of a motorcyclist being

involved in a crash, and thus their likelihood of incurring any type of injury


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In addition to the previously mentioned design issues, there are also various styles ohelmets which aord dierent protection. Te our most common types are:

Full-ace helmets(Figure .a)Tese helmets oer acial protection in addition to impact protection. Teir prin-cipal eature is a chin bar that extends outwards, wrapping around the chin and jawarea. Extending above the jaw, there is a vision port that allows the wearer maximumrange o sight, in line with the requirements or peripheral and vertical vision.

Open-ace helmets (Figure .b)Open-ace helmets give standard protection rom impact with their hard outer shelland crushable inner liner. Compared to the ull-ace type, they oer only limited

Does the colour of a

helmet matter?

Research in New Zealand has examined

whether the colour of a helmet affects

the risk of a crash The study com-

pared motorcycle drivers who had been

involved in motorcycle crashes that led

to hospital treatment with those who

had not (as a control group), while exam-

ining the colour of the helmets worn

by all study participants The resultsshowed that higher proportions of driv-

ers who had been involved in crashes reported wearing black helmets, while

fewer reported white helmets Compared with wearing a black helmet, use of a

white helmet was associated with a 24% lower risk of crash Similarly, having a

light-coloured helmet compared with a dark-coloured one was associated

with a 19% lower risk of a crash The researchers concluded that some 18% of

crashes could be avoided if non-white helmets were eliminated; similarly, 11%

could be avoided if all helmets were not dark

Although the results of the study cannot necessarily be generalized to othersettings or countries, it seems reasonable to assume that there is greater pro-

tection from white helmets as opposed to black ones, and from lighter-coloured

ones generally as against darker ones The study therefore suggests that poli-

cies encouraging white and lighter-coloured helmets can help prevent motorcycle

crashes

Source:11

A light-coloured helmet has been shown to reduce the

risk of a crash.

CopyrightWHO


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protection or the jaw and chin area. Tey may or may not have retractable visors toprotect the eyes.

Hal-head helmets (Figure .c)Tese helmets provide protection by means o a hard outer shell and a crushableinner liner. Tey do not oer protection or the chin or jaw area and are rarelyequipped with visors. Te hal-head helmet may or may not have ear faps attached tothe retention system.

Helmets or tropical use (Figure .d)Tese are helmets specically designed or South Asian and South-East Asian coun-tries with extremely hot and humid climates. Tey are actually hal-head helmetswith ventilation holes to provide a maximum fow o air so as to reduce the heat.

Teir extreme lightness o weight is achieved by using semi-rigid vacuum-ormingPVC material.

Figure 1.5 Helmet styles

a Full-face b Open-face c Half-head d Tropical

A

siaInjury

PreventionFoundation

Children: what type of helmet?

Few countries have helmets specically designed for chil-

dren, which results in children either not wearing helmets

or else being force to wear adult-size helmets In some

countries, for example Viet Nam and Thailand, however,

childrens helmets are now being designedHelmet developed in Thailand for

children aged 2.


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Systematic reviews have been published examining the eectiveness o both motor-cycle helmets and bicycle helmets (13,14). Te review on motorcycle helmets includ-ed 3 studies, and summarized the current available evidence on helmets and theirimpact on mortality, as well as on head, ace and neck injuries, ollowing motorcyclecrashes. able . provides a summary o the main results o this review.

Table 1.1 Summary of systematic review of effectiveness of motorcycle

helmets

Source: 13

Not wearing a helmet Wearing a helmet

increases the risk of sustaining a head injury;

increases the severity of head injuries;

increases the time spent in hospital;

increases the likelihood of dying from a headinjury

decreases the risk and severity of injuries byabout 72%;

decreases the likelihood of death by up to39%, with the probability depending on thespeed of the motorcycle involved;

decreases the costs of health careassociated with crashes

Te ollowing are the main conclusions o this research:

Motorcycle helmets reduce the risk o mortality and head injury in motorcycleriders who crash, although the eect on death may be modied by other actorssurrounding the crash, such as the speed the motorcyclist was travelling at whenthe crash occurred. Crashes at higher speeds may result in multiple injuries likelyto cause death, regardless o how well the head is protected.Tere was not enough evidence to determine the eect o motorcycle helmets onace or neck injuries, although some studies suggest that helmets have no eect onthe risk o neck injuries but are protective or ace injuries.Tere was insucient evidence to demonstrate whether dierences in helmettypes (ull-ace versus open-ace) coner more or less advantage in injury reduc-

tion. Further research should be conducted to determine the eectiveness (andcost eectiveness) o dierent helmet types especially those used in low-incomeand middle-income countries on mortality and on head, neck and ace injuries.Increasing motorcycle helmet use in countries where such use has been low is likelyto dramatically reduce head injury and death. Policy-makers would do well to con-sider measures to increase helmet use, such as legislation or compulsory helmetuse and its enorcement, along with community education campaigns.

A systematic review has also been conducted on bicycle helmets. Te review on theeectiveness o bicycle helmets in reducing head and acial injuries ound them tobe eective at reducing head and brain injury or all ages o bicyclists (see Box .2).

However, there is a broader debate about whether helmet use is the best way to


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1.4 Helmet programmes are effective at getting helmets on heads

Laws making helmet use compulsory are important in increasing the wearing o hel-mets, especially in low-income and middle-income countries where helmet-wearingrates are low, and where there are large numbers o users o motorized two-wheelers.

Tere have been many studies that have evaluated the impact o motorcycle helmetlaws on helmet-wearing rates, head injury or death (see Box .4). When mandatoryhelmet laws are enorced, helmet-wearing rates have been ound to increase to %or higher (1719); when such laws are repealed, wearing rates all back to generallyless than % (2022).

Te pattern is similar with regard to the eects o such laws on head injuries. Anumber o studies have shown that the introduction o helmet laws reduce headinjuries and death, while many studies demonstrate that an increase in head injuriesand death results when helmet laws are repealed (see Box .). For example, a numbero studies in exas, USA, have shown that introducing comprehensive motorcy-cle helmet legislation is associated with a decrease in injuries and atalities. In oneo these studies there was a decrease in injury rates o between % (23), whileanother showed more striking reductions o 2% in head injuries and atalities(24). Conversely, repeal o helmet legislation in Florida led to increases o between.2%2.% in both atalities and atality rates (25, 26).

It is clear that introduction o ull legislation (that is, applying to the whole popula-tion) is associated with a signicant decrease in head injuries and deaths. Tere is aclear imperative or policymakers to legislate and enorce motorcycle helmet wearingat a population level. Weak or partial legislation that mandates helmet wearing orthose less than 2 years, without medical insurance or only on certain types o roadsdoes not eectively protect those at risk and should be upgraded to comprehensivecoverage.

However, it is important to note that most studies that examine the impact omotorcycle helmet laws have been conducted in high-income countries where legisla-

tion when introduced is heavily enorced, and motorcycle helmet quality is high.Although it seems very likely that the introduction o motorcycle helmet-wearinglegislation in low-income or middle- income countries will decrease atality ratesamong motorcyclists at a population level i helmet-wearing rates are high, thereare several unknown actors. Availability o high-quality helmets is not widespreadacross such countries and the eectiveness o the available helmets is also unknown.Enorcement is also a actor that must be considered. In low-income and middle-income countries where police resources are constrained and community attitudesto helmet wearing are not supportive o legislation, eective enorcement requireswidespread government support.


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Legislation is most likely to work where high-quality helmets are accessible andaordable, where enorcement is comprehensive and there is widespread communityeducation on the benets o helmet use.

It is thereore important that when motorcycle helmet wearing legislation is intro-duced in low-income and middle-income countries, there is eective enorcement, aready supply o aordable helmets o appropriate quality (which meet internationalor country standards), and widespread education campaigns or both communityand police. It is also imperative that the evaluation o such legislation is planned priorto implementation, so that evaluation o the eectiveness o the intervention may becarried out.

Until 2000, Italian laws on the use of helmets

applied only to drivers of motorcycles, while moped

drivers over the age of 18 were exempt from wear-

ing a helmet In 2000, Italy adopted a much more

comprehensive law aimed at reducing the effects of

motorcycle crashes, requiring the use of helmets

for all motorcycle and moped drivers and their pas-

sengers, irrespective of age

A study carried out to assess the impact of the new

law looked at: the effect on rates of helmet wearing;

changes in the number of hospital admissions of

traumatic brain injury; and the type of brain inju-

ries admitted to hospital as a result of motorcycle

crashes. The assessment revealed:

a considerable rise in helmet-wearing rates across

the country, by up to 95% in some regions;

the highest increase in wearing rates occurring in

areas where the adoption of the law was combined

with a public media campaign and strong police

enforcement;

no decrease in the number of two-wheeled motor-

ized vehicles in use throughout the country;

a 66% decrease in admissions of traumatic brain

injury for motorcycle and moped crashes;

a 31% decrease in traumatic brain injury admis-

sions to neurosurgical hospital units;

a fall, to almost zero, in the number of blunt impact

head injuries (epidural haematomas) among

injured moped riders admitted to hospital

The study demonstrates the effect of police enforce-

ment of helmet use for all riders of two-wheeled

motorized vehicles It underlines the fact that man-

datory helmet use is an effective measure to prevent

traumatic brain injury

BOX 14: Italys motorcycle helmet law and traumatic brain injury

Until 2000, Italian laws on the use of helmets

applied only to drivers of motorcycles, while moped

drivers over the age of 18 were exempt from wear-

ing a helmet In 2000, Italy adopted a much more

comprehensive law aimed at reducing the effects of

motorcycle crashes, requiring the use of helmets

for all motorcycle and moped drivers and their pas-

sengers, irrespective of age

A study carried out to assess the impact of the new

law looked at: the effect on rates of helmet wearing;

changes in the number of hospital admissions of

traumatic brain injury; and the type of brain inju-

ries admitted to hospital as a result of motorcycle

crashes. The assessment revealed:

a considerable rise in helmet-wearing rates across

the country, by up to 95% in some regions;

the highest increase in wearing rates occurring in

areas where the adoption of the law was combined

with a public media campaign and strong police

enforcement;

no decrease in the number of two-wheeled motor-

ized vehicles in use throughout the country;

a 66% decrease in admissions of traumatic brain

injury for motorcycle and moped crashes;

a 31% decrease in traumatic brain injury admis-

sions to neurosurgical hospital units;

a fall, to almost zero, in the number of blunt impact

head injuries (epidural haematomas) among

injured moped riders admitted to hospital

The study demonstrates the effect of police enforce-

ment of helmet use for all riders of two-wheeled

motorized vehicles It underlines the fact that man-

datory helmet use is an effective measure to prevent

traumatic brain injury

BOX 14: Italys motorcycle helmet law and traumatic brain injury

Source: 19


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In the United States, the enactment of motorcycle

helmet laws is under the jurisdiction of individual

states, and has been the subject of ongoing debate

on the balance between personal freedom and pub-

lic health Those opposed to mandatory helmet laws

argue that such laws infringe upon their individual

rights On the other hand, those who support them

argue that since society bears the burden of the

nancial costs of motorcycle crashes, there is a

public interest in and a justication for legislating

for helmet use Over the years, states have vari-

ously enacted, repealed, and re-enacted universal

motorcycle helmet laws laws applying to all riders

of motorcycles

In 1996, a federal policy tying motorcycle helmet

laws to the receipt of government funding led to 47

states enacting universal helmet laws After this

policy was withdrawn the following year, though,

many states quickly repealed their helmet laws, or

amended them so that they applied only to young

riders

The consequences of these repeals of helmet laws

have been as follows:Observed helmet use in a number of states

dropped from nearly full compliance while the law

existed, to around 50% after repeal

In several states, there were immediate and dra-

matic increases in the numbers of motorcyclists

without helmets who were involved in crashes

Deaths of riders under the age of 21 increased

even though the law still applies to these users

In Florida, deaths to these young riders increased

by 188 percent

Increases were recorded in head injuries and

fatalities among motorcycle users For example,

the rate of motorcyclist fatalities rose by 37% and

75% in Kentucky and Louisiana, respectively, fol-

lowing the repeal of their mandatory laws.

Associated with the increase in severity of head

injuries was an increase in the costs of treating

them For example, in Florida the total gross acute

care costs charged to hospital-admitted motorcy-

clists with head, brain or skull injury more than

doubled, from US$ 21 million to US$ 41 million,

adjusted for ination The average costs per case

rose from US$ 34 518 to US$ 39 877 in the 30

months after the law change.

The pattern of evidence from the states that have

altered their laws on helmet use indicates that

motorcycle helmets reduce the severity of injuries

incurred in a crash; that the repeal of helmet laws

decreases helmet use; and that states that repeal

universal helmet laws experience an increase in

motorcycle fatalities and injuries

BOX 15: Helmet laws: the effect of repeal

Observed helmet use before and after repeal of helmet law in

Kentucky and Louisiana

Change in fatality and injury rates two years after helmet law

repeal in Kentucky and Louisiana

Source: 26, 29


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Summary

Te risk o being injured or killed in a trac collision is much higher or motorcy-cle users than or users o our-wheeled vehicles.Motorcycle users make up a high proportion o overall trac injuries and death,particularly in low-income and middle-income countries, where motorcycle own-ership is high.Injuries to the head and neck are the main causes o death, severe injury and dis-ability among users o motorcycles and bicycles. In some countries head injuriesare estimated to account or up to % o such atalities.Helmets aim to reduce the risk o serious head and brain injuries by reducing the

impact o a orce or collision to the head.Te correct use o a helmet considerably decreases the risk and severity o headinjuries.Programmes that set and enorce mandatory helmet legislation are eectiveincreasing helmet-wearing rates and thus reducing head injuries and atalities.Tere is strong international support or helmet-wearing programmes.


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References

. Peden M et al, eds. World report on road trac injury prevention. Geneva: World HealthOrganization, 24 (www.who.int/world-health-day/24/inomaterials/world_report/en/,accessed 4 July 2).

. Koornstra M et al. Sunower: a comparative study o the development o road saety in Sweden,the United Kingdom and the Netherlands. Leidschendam, SWOV (Institute or Road SaetyResearch), 23.

. Mohan D. rac saety and health in Indian cities.Journal o ransport and Inastructure, 22,:4.

. rac Saety Facts. Motorcycle helmet laws. Washington, D.C., National Highway rac SaetyAdministration, 24 (www.nhtsa.dot.gov/people/injury/New-act-sheet3/MotorcycleHelmet.

pd, accessed 4 July 2).. Suriyawongpaisal P, Kanchanusut S. Road trac injuries in Tailand: trends, selected underlying

determinants and status o intervention.Injury Control and Saety Promotion, 23, :4.

6. Umar R. Helmet initiatives in Malaysia. In:Proceedings o the 2nd World Engineering Congress.Kuching, Sarawak, Malaysia, Institution o Engineers, July 22.

7. Zhang J et al. Motorcycle ownership and injury in China.Injury Control & Saety Promotion,24, :3.

8. Motorcycle saety helmets. COS 32. Brussels, Commission o the European Communities, 2.

9. Blincoe L et al. Te economic impact o motor vehicle crashes, 2000.Washington, D.C., NationalHighway rac Saety Administration, 22 (DO HS--44).

0. Kulanthayan S et al. Compliance o proper saety helmet usage in motorcyclists.Medical Journal

o Malaysia, 2, :444.. Wells S et al. Motorcycle rider conspicuity and crash related injury: case-control study.British

Medical Journal, 24, 32:.

. Brandt M et al. Hospital cost is reduced by motorcycle helmet use.Journal o rauma, Inectionand Critical Care, 22, 3:44.

. Liu B et al. Helmets or preventing injury in motorcycle riders. Te Cochrane Database oSystematic Reviews, 2 (4).

. Tompson DC, Rivara FP, Tompson R. Helmets or preventing head and acial injuries inbicyclists. Te Cochrane Database o Systematic Reviews, 2 (4).

. Ivers RQ et al. Motorcycle helmet legislation or preventing injuries in motorcyclists. (Protocol)Te Cochrane Database o Systematic Reviews 24 (3).

6. Macpherson A, Spinks A. Bicycle helmet legislation or the prevention o head injuries.(Protocol) Te Cochrane Database o Systematic Reviews 2 (3).

7. Kraus JF, Peek C, Williams A. Compliance with the 2 Caliornia Motorcycle Helmet UseLaw.American Journal o Public Health, ;:.

8. Chiu W et al. Te eect o the aiwan motorcycle helmet use law on head injuries [Commentin: American Journal o Public Health 2;:2].American Journal o Public Health2;:3.

9. Servadei F et al. Eect o Italys motorcycle helmet law on traumatic brain injuries.InjuryPrevention, 23, :22.

0. urner P, Hagelin C.Florida Motorcycle Helmet Use: Observational Survey and rend Analysis.Florida Department o ransportation, 24.


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How to assess the situation

in your country

2


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How to assess the situation

in your country2.1Whydoyouneedtoassessthesituation?. 27

211. The.quality.o.the.data . 28

2.2Howwidespreadistheproblemofnon-useof

helmets?. 29

221. How.big.is.the.motorcycle.injury.problem?. 29

222. What.is.the.helmet-wearing.rate.in.the.area.being.

c o n s i d e r e d ? . 3 5

223. Why.dont.people.wear.helmets?. 41

2.3Howtoassesswhatisalreadyinplace . 44

231. Who.is.in.charge.o.road.saety,.and.what.unds.

a r e . t h e r e . o r . i t ? . 4 5

232. Who.are.the.stakeholders?. 45

233. Is.there.a.helmet.use.law.in.place?. 47

234. Is.there.a.helmet.standard.in.place?. 47

235. Have.any.helmet.programmes.been.attempted.so.ar?. 48

236. Using.the.situational.assessment.to.prioritise.actions . 51

Summary. 51

References . 52


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Module 1 explained why helmets are needed to reduce the atalities andinjuries that are associated with motorcycle and bicycle use. However, beore

designing and implementing a strong helmet saety programme in your country orregion, it is important to assess the situation. Many o the steps that you will need totake or this process will also be necessary when you monitor the helmet programme,once you have it in place. Te sections in this Module are structured as ollows:

2. Why do you need to assess the situation? An eective helmet programmewill be based on an understanding o the extent o the problem in a country orregion. Tis inormation can also be used in support o establishing a programme.2.2 How widespread is the problem o non-use o helmets? Tis sectiondescribes how to assess the extent o the problem o non-use o helmets among

motorcycle users in the project region. It begins with guidance on assessing theextent o the problem o head injuries that result rom motorcycle crashes. It thenprovides a detailed explanation o how to conduct a study to determine what thehelmet-wearing rate is in the project area. Finally it provides advice on examiningwhy people do not wear helmets.2. How to assess what is in place already: Tis section describes the questionsthat need to be asked in order to collect inormation on what national processesare underway in the country or region with regard to helmet use. o do this, youwill need to nd out who is responsible or road saety, and consider all those whomay have an interest in a helmet programme. Te module guides you on how tocollect comprehensive inormation on the institutional and legislative structuresthat are in place that might have an impact on your programme, as well as the needto nd out about any existing or previous helmet programmes in the project area,in order to learn rom these experiences, and to identiy the potential resources(nancial, personnel, and institutional) or uture helmet programmes.

2.1 Why do you need to assess the situation?

Tose planning a helmet programme may already have an understanding o some othe inormation and issues around helmet use in their country or region, and thusmay eel they do not need to conduct a situational assessment. Nonetheless, conduct-ing a well-planned and thorough situational assessment is strongly advised prior tostarting any new helmet use programme. Tis does not necessarily imply a prolongedand complicated process, but can mean simply taking the time to search or and com-pile all the existing relevant inormation. Tere are three main reasons or assessingthe situation beore starting a helmet programme.

o identiy the problem o lack o helmet use among motorcyclists and to depict thescale o the problem. Te inormation gathered will illustrate how important head

injuries are among motorcycle users in the project area; where the greatest need


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or helmets is; the cost o motorcyclists not wearing helmets; and the reasons whymotorcyclists do not wear helmets. Tis in turn helps set priorities or action.Similar evidence would be required i you were contemplating putting a bicyclehelmet programme in place.o provide evidence or arguments on why helmet use is essential and why itshould be supported. A helmet programme, in order to be successul, needs thebacking o both policy-makers and the public. Accurate data on actors such ashelmet use and head injuries among motorcyclists in the project area will help toshow what can be gained by implementing a programme, and provide argumentsto convince policy-makers and the general public o the need or a comprehensivehelmet-use programme. Module provided background data on the evidence orthe eectiveness o helmets in reducing head injuries that can also be used in sup-

port o setting up a local programme.o provide baseline indicators that can be used or monitoring and evaluating aprogramme. Tis may include quantitative inormation such as helmet-wearingrates, as well as qualitative inormation, such as public opinion on helmet use, orinormation on compliance with legislation.

2.1.1 The quality of the data

Good data are important in assessing the situation. Tis means data that are appro-

priate, accurate, complete, and reliable. In collecting data, one can also identiy prob-lems in the data system itsel. For example, in collecting data on helmet use in yourregion, it may become clear that the data on helmet wearing rates are incomplete.Knowledge o such shortcomings in the data can help set realistic objectives as parto your programme.

Nonetheless, in many countries, where reporting systems are not well established orcoordinated, some o the necessary data will not be available. Lack o data should notbe used as an excuse or inaction or ignoring a countys problem o motorcycle-relat-ed head injuries. Some country-level data are always available, no matter how rudi-mentary these may be, and these can be used as a starting point to develop a strategy

or increasing helmet use.Methods or collecting data will vary and the data obtained will probably alsodepend on the source. Hospital data on crashes and injuries incurred, or instance,may be biased because they only take into account cases that are actually brought tothe hospital. Similarly, police data on crashes will only record those cases the policeinvestigate. However, either o these two sources is a good starting point.

Data collection should ideally be led by a person who has experience in epidemiol-ogy. Module 3 discusses the establishment o a working group to develop a helmetprogramme. Te public health expert in the working group is probably the most

suited person to take charge o this task.


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How

toassessthesituationinyourcountry

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2.2 How widespread is the problem of non-use of helmets?

Te next two sections guide users on how to gather the inormation needed orassessing the situation. Collecting such detailed data on some o these issues will bean essential part o any helmet use intervention, both as a component o the pro-gramme itsel, and or the purpose o monitoring and evaluation.

2.2.1 How big is the motorcycle injury problem?

Tis assessment involves examining data on road trac crashes in order to gaugethe extent o the problem with regards to motorcyclists, and collecting inormation

on head injuries among motorcycle users.

Collecting data on road trac crashes

Developing appropriate measures to address a road saety problem requires accuratedata on the extent o the problem o road trac crashes, and in particular, on motor-cycle crashes and the head injuries that result. Te data should be used to point to thedangers acing motorcyclists, and to emphasize the need or an action programme.

Inormation will be needed on the incidence, severity and types o crashes, whilea thorough understanding o the causes o crashes is also important. Te data will

also give inormation on locations with an increased risk or motorcyclists, as wellas on riders at increased risk. Such inormation will be valuable or targeting theprogramme. For instance, it may turn out that busy urban roads are a high-risk area,or rural roads; young males may be the group ound to be at special risk, or sel-employed delivery riders.

o collect these data, the ollowing questions need to be asked:How many injuries and deaths are there as a result o road trac crashes in theproject region? Note that it is important or the working group to predene theunit o assessment (see Module 3). For example, this may be the entire country, orit may be a particular province/state, or town or community.

What is the scale o the problem o motorcycle crashes in terms o the numbero crashes and the number o atalities? What proportion o the overall road traccrashes does this make up?How does this problem compare, in terms o its scale and the burden on society,with other local public health problems?Who are those most likely to be involved in motorcycle crashes?

Te indicators to be used here include:the number o registered motorcycles as a proportion o all motorized vehicles;the rate o motorcycle crashes (per vehicles, or per people);the distribution o motorcycle crashes across dierent road types;the age and gender o riders and passengers involved in these crashes.


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Who will have this kind o inormation?

Te trafc police are the most likely source or data on trafc crashes. Such data willprobably also be handled by the countrys trafc saety agency or transportation depart-ment, so that inormation rom these bodies should also be considered ofcial data.

In practice, ull inormation on these actors is rarely available, as data may not becomplete. Issues o underreporting in police records exist even in those countrieswith a good road saety record.

Other sources o data o this kind might be nongovernmental organizations, univer-sities, research organizations, or insurance companies.

Motorcyclist deaths have been a signicant public

health problem in Cali for many years Vehicle-related

injury is the fth leading cause of death in the Colom-

bian city, with vulnerable road users pedestrians

and motorcyclists the most affected In 199394,

motorcyclists accounted for 30% (1393 cases) of all

motor vehicle-related deaths in Cali Of these, 85%

were men, though the passengers injured in these

motorcycle crashes were predominantly womenAlcohol consumption was a contributing factor

among a large proportion of those injured Over 40%

of casualties occurred on weekends, when there are

fewer patrols on the streets

In 1993, a Fatal Injury Surveillance System was set

up through the mayors ofce This has helped not

only surveillance efforts, but also the identication

of prevention strategies and the assessment of

their impact

Since then, various other steps have been taken In

1996, a mandatory helmet law for drivers of motor-

cyclists was introduced, resulting in a decrease in

motorcyclist deaths The following year, the law

was extended to include motorcycle passengers

as well

In 2001, three strategies were introduced to

reduce motorcycle crashes: a regulation requiring

the wearing of reective vests, obligatory attend-

ance at a driving school following a trafc violation,

and a weekend ban on motorcyclists As a result,

the number of motorcyclist fatalities decreased

considerably The reective vest requirement was

withdrawn, for no apparent reason, the following

year, but reinstated a year later, along with a new

national road code

An analysis of the trends in motorcycle fatalities

since 1996 shows that motorcycle death rates have

fallen from 97 to 52 per 100 000 population,

a decrease of 46% The data suggest that strict

enforcement of laws on helmet use has been an

important factor contributing to this decrease

BOX 21: Preventing motorcycle deaths in Cali, Colombia

Although no two countries or regions will be identical in the circumstances and

conditions with regard to motorcycle crashes and head injuries, where data from

a country are lacking, it can be helpful to examine what data are available from similar

or neighbouring countries Such data can be used in support of a helmet programme in

the c

Documents

Helmet Manual