13
This article was downloaded by: [186.115.34.218] On: 22 February 2014, At: 11:21 Publisher: Taylor & Francis Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK International Journal of Injury Control and Safety Promotion Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/nics20 Trends in fatal motorcycle injuries in the Americas, 1998–2010 Eugênia M. S. Rodrigues a , Andrés Villaveces b , Antonio Sanhueza a & José A. Escamilla- Cejudo a a Pan American Health Organization / World Health Organization, Washington, DC b Cisalva Institute, Universidad del Valle, Cali, Colombia Published online: 28 May 2013. To cite this article: Eugênia M. S. Rodrigues, Andrés Villaveces, Antonio Sanhueza & José A. Escamilla-Cejudo , International Journal of Injury Control and Safety Promotion (2013): Trends in fatal motorcycle injuries in the Americas, 1998–2010, International Journal of Injury Control and Safety Promotion, DOI: 10.1080/17457300.2013.792289 To link to this article: http://dx.doi.org/10.1080/17457300.2013.792289 PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Versions of published Taylor & Francis and Routledge Open articles and Taylor & Francis and Routledge Open Select articles posted to institutional or subject repositories or any other third-party website are without warranty from Taylor & Francis of any kind, either expressed or implied, including, but not limited to, warranties of merchantability, fitness for a particular purpose, or non-infringement. Any opinions and views expressed in this article are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor & Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions Taylor & Francis and Routledge Open articles are normally published under a Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0/. However, authors may opt to publish under a Creative Commons Attribution-Non-Commercial License http://creativecommons.org/licenses/by-nc/3.0/ Taylor & Francis and Routledge Open Select articles are currently published under a license to publish, which is based upon the Creative Commons Attribution-Non-Commercial No-Derivatives License, but allows for text and data mining of work. Authors also have the option of publishing an Open Select article under the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0/.

Tendencia de lesiones fatales en motociclitas las americas 1998 2010

Embed Size (px)

DESCRIPTION

 

Citation preview

Page 1: Tendencia de lesiones fatales en motociclitas las americas 1998 2010

This article was downloaded by: [186.115.34.218]On: 22 February 2014, At: 11:21Publisher: Taylor & FrancisInforma Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House,37-41 Mortimer Street, London W1T 3JH, UK

International Journal of Injury Control and SafetyPromotionPublication details, including instructions for authors and subscription information:http://www.tandfonline.com/loi/nics20

Trends in fatal motorcycle injuries in the Americas,1998–2010Eugênia M. S. Rodriguesa, Andrés Villavecesb, Antonio Sanhuezaa & José A. Escamilla-Cejudoa

a Pan American Health Organization / World Health Organization, Washington, DCb Cisalva Institute, Universidad del Valle, Cali, ColombiaPublished online: 28 May 2013.

To cite this article: Eugênia M. S. Rodrigues, Andrés Villaveces, Antonio Sanhueza & José A. Escamilla-Cejudo , InternationalJournal of Injury Control and Safety Promotion (2013): Trends in fatal motorcycle injuries in the Americas, 1998–2010,International Journal of Injury Control and Safety Promotion, DOI: 10.1080/17457300.2013.792289

To link to this article: http://dx.doi.org/10.1080/17457300.2013.792289

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained inthe publications on our platform. Taylor & Francis, our agents, and our licensors make no representations orwarranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Versionsof published Taylor & Francis and Routledge Open articles and Taylor & Francis and Routledge Open Selectarticles posted to institutional or subject repositories or any other third-party website are without warrantyfrom Taylor & Francis of any kind, either expressed or implied, including, but not limited to, warranties ofmerchantability, fitness for a particular purpose, or non-infringement. Any opinions and views expressed in thisarticle are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. Theaccuracy of the Content should not be relied upon and should be independently verified with primary sourcesof information. Taylor & Francis shall not be liable for any losses, actions, claims, proceedings, demands,costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly inconnection with, in relation to or arising out of the use of the Content.

This article may be used for research, teaching, and private study purposes. Any substantial or systematicreproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in anyform to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions

Taylor & Francis and Routledge Open articles are normally published under a Creative Commons AttributionLicense http://creativecommons.org/licenses/by/3.0/. However, authors may opt to publish under a CreativeCommons Attribution-Non-Commercial License http://creativecommons.org/licenses/by-nc/3.0/ Taylor & Francisand Routledge Open Select articles are currently published under a license to publish, which is based upon theCreative Commons Attribution-Non-Commercial No-Derivatives License, but allows for text and data mining ofwork. Authors also have the option of publishing an Open Select article under the Creative Commons AttributionLicense http://creativecommons.org/licenses/by/3.0/.

Page 2: Tendencia de lesiones fatales en motociclitas las americas 1998 2010

It is essential that you check the license status of any given Open and Open Select article to confirmconditions of access and use.

Dow

nloa

ded

by [

186.

115.

34.2

18]

at 1

1:21

22

Febr

uary

201

4

Page 3: Tendencia de lesiones fatales en motociclitas las americas 1998 2010

Trends in fatal motorcycle injuries in the Americas, 1998–2010

Eugenia M. S. Rodriguesa*, Andr�es Villavecesb, Antonio Sanhuezaa and Jos�e A. Escamilla-Cejudoa

aPan American Health Organization / World Health Organization, Washington, DC; bCisalva Institute,Universidad del Valle, Cali, Colombia

(Received 11 December 2012; final version received 18 February 2013)

Injuries, disabilities and deaths among motorcyclists have been rising worldwide but what is happening in the AmericanContinent is not completely known. Deaths from motorcycle crashes of the Pan American Health Organization database(PAHO/WHO, 1998–2010) were included in an ecologic multi-national study to quantify the temporal trends and to esti-mate the association between motorcycle riders’ deaths and selected socio-economic indicators. Mortality rates increasedin all sub-regions. The highest increase was reported in the countries of the Andean sub-region (Ecuador, 78.3%) and Mes-oamerica (Costa Rica, 60.0%). Poorer countries fared worse in terms of motorcycle mortality relative to richer countries,as did more unequal ones. Recent economic changes, rapid increment of motorisation rates, affordability of motorcyclesover public transportation, lack of adequate public transportation policies and other insufficient measures aimed at improv-ing safety can explain these trends.

Keywords: motorcycles; trends; mortality; surveillance; Americas

Introduction

In the last two decades, injuries, disability and deaths

among motorcycle users have been rising worldwide dis-

proportionally affecting young males (Franco Arias, 2010a;

Instituto de Pesquisa Economica Aplicada, 2006; Zentner,

Dellinger, Adkins, & Greene, 1995). Motorcycle riders are

especially vulnerable to injuries because of the high speeds

they can acquire, coupled with small vehicular structures

that offer poor protection and are more difficult to be seen

in traffic. Consequently riders involved in crashes are more

likely to die or be severely injured due to high frequency of

head, chest and leg injuries (Peden et al., 2004).

In the Americas and the Caribbean, the number of reg-

istered vehicles has been estimated at over 387 million of

which approximately 24 and a half million are motor-

cycles. Motorisation rates vary from country to country

from 55 per 1000 in Peru to 779 per 1000 in the United

States as well as difference of the type of vehicles is

observed (Pan American Health Organization, 2009).

There are also several sub-regional variations.

In this region, traffic-related injuries are the number

one cause of death among children aged 5 to 14 years and

the second cause among those aged 15 to 44 years. In

2007, 142,252 traffic-related deaths occurred in this

region and an estimated 5 million people were injured

(Pan American Health Organization, 2009). The standar-

dised road traffic mortality rate in the region is 15.8 per

100,000 population with great disparity among countries,

ranging from 4.3 per 100,000 in Uruguay to 21.8 per

100,000 in Venezuela. Motorcyclists accounted for 12%

of all traffic-related fatalities. The percentage among sub-

regions varies from 14% in the Southern Cone to 6% in

Mesoamerica. Since the late nineties, fatal and non-fatal

motorcycle injuries have been rising in several countries

with the consequent economic and social costs associated,

hence increasing the public health burden in the region

(Pan American Health Organization, 2009). A study from

the United States documented that motorcyclists incurred

higher costs with respect to injury incidence. In 2000,

motorcyclists accounted for 6% of fatal and non-fatal

injuries, but 12% of the costs, totalling approximately

$12 billion of the $99 billion total cost of motorcycle

fatalities and injuries (Naumann, Dellinger, Zaloshnja,

Lawrence, & Miller, 2010).

Young adult males are the main users of motorcycles

in Latin America. As a consequence, they account for the

largest proportion of motorcycle deaths and injuries. Inju-

ries among these young populations further increase the

public health burden in the region through longer periods

of rehabilitation, disability and economic losses. The

Latin American population is relatively young and about

28% of Latin Americans are under 15 years of age

(Franco Arias, 2010b). Considering that young adults are

mostly at risk for being involved in motorcycle crashes,

motorcycle safety constitutes an even greater priority for

the region (Hazen & Ehiri, 2006).

While many studies have looked at motorcycle inju-

ries trends in the US and Canada (Beck, Dellinger, &

*Corresponding author. Email: [email protected]

� 2013 The Author(s). Published by Taylor & Francis.

This is an Open Access article. Non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly attributed, cited, and is not

altered, transformed, or built upon in any way, is permitted. The moral rights of the named author(s) have been asserted.

International Journal of Injury Control and Safety Promotion, 2013

http://dx.doi.org/10.1080/17457300.2013.792289

Dow

nloa

ded

by [

186.

115.

34.2

18]

at 1

1:21

22

Febr

uary

201

4

Page 4: Tendencia de lesiones fatales en motociclitas las americas 1998 2010

O’Neil, 2007; Watson, Zador, & Wilks, 1980), evaluated

policies (Hertz, 1989; Hijar, Perez-Nunez, Inclan-

Valadez, & Silveira-Rodrigues, 2012; Villaveces et al.,

2003), and looked at economic consequences of motorcy-

cle injuries in those countries (Muelleman, Mlinek, &

Collicott, 1992; National Highway Traffic Safety Admin-

istration, 2011), very few have focused on motorcycle

morbidity and mortality in the rest of the Americas. A

couple of studies from Brazil have documented increases

in motorcycle injuries at a national level (Chandran,

Sousa, Guo, Bishai, & Pechansky, 2012; Instituto

de Pesquisa Economica Aplicada, 2006) or described

motorcycle injuries in more detail in Sao Paulo state

(Gawryszewski et al., 2009; Silva, Cardoso, & Santos,

2011). Another study from Cali, Colombia documented

increases in motorcycle mortality and estimated changes

associated to the implementation of a helmet law

(Espitia-Hardeman, V et al., 2008), and one from Jamaica

documented associated morbidity and mortality among

people seen at a large hospital (Crandon, Harding,

Cawich, McDonald, & Fearron-Boothe, 2009).

The dearth of information about motorcycle mortality

in the Americas highlights the need to document overall

regional trends. This study addresses the magnitude of the

problem at a regional level, by sub-regions, and by com-

paring countries with similar economic indicators to high-

light the seriousness of the problem, and to raise

hypotheses that could explain this phenomenon.

Materials and methods

To investigate the mortality risk throughout the time of a

motorcycle rider injured in a transport crash in the Ameri-

can Continent, we undertook an ecologic comparison –

trend study among Member Countries of the Pan Ameri-

can Health Organization, the regional office of the World

Health Organization in the Americas (PAHO/WHO). We

initially considered 48 countries with an approximate total

population of 930 million in 2009. Countries were

included in the final analysis if they complied with the fol-

lowing conditions: (a) they had data for at least 7 years of

the 13-year study period, (b) they had a minimum popula-

tion of 400 thousand inhabitants and (c) if they had a

medium to good data quality index as assessed in 2008 by

common PAHO health indicators for the Americas (Pan

American Health Organization, 2008). Our final selection

of countries yielded 17 nations for the overall regional

comparison. Puerto Rico has been considered as a nation

although it is an unincorporated territory of the United

States of America. The sub-regional comparison (second

level of inference), included country groupings according

to commonly used PAHO categories: North America

(United States of America and Canada); Mesoamerica

(Costa Rica, Mexico, Nicaragua, Panama); Latin Carib-

bean (Cuba, Puerto Rico); Andean (Colombia, Ecuador,

Venezuela); Southern Cone (Argentina, Brazil, Chile,

Paraguay); and Non-Latin Caribbean (Suriname, Trinidad

& Tobago).

Mortality data were drawn from the Regional Data-

base on Mortality compiled by PAHO’s Health Analysis

Unit from 1998 to 2010. The Regional Database on Mor-

tality compiles information from the national death regis-

tries of all Member Governments provided on an annual

basis. Deaths from motorcycle riders injured in transport

crashes were classified according to the International

Classification of Diseases, 10th revision (ICD – 10) under

codes V20 – V29 “Motorcycle rider injured in transport

crash”.

Data analysis included descriptive statistics by coun-

try, sub-region and region. Crude mortality rates were

calculated using as the numerator the number of deaths

in motorcycle crashes and as denominator the annual

mid-period population by age and sex, provided by the

United Nations, Population Division for the study period.

For between country and between sub-regions compari-

sons we used age-adjusted mortality rates, using as

standard population the WHO world population

age-structure constructed for the period 2000–2025. The

use of an average world population, as well as a time

series of observations, removes the effects of historical

events such as wars and famine on population age

composition (Ahmad, Boschi-Pinto C, Murray, Lozano,

& Inoue, 2001).

Using negative binomial models we explored indepen-

dently the bivariate association between motorcycle mor-

tality and sub-region, sex and age group respectively. We

also considered the association of socio-economic indica-

tors and motorcycle deaths using these models. Our expo-

sure variables for this latter model included Gross

National Income (GNI) converted to international dollars

using purchasing power parity rates and the Highest 20%/

Lowest 20% income ratio (H20%/L20%). The median

value of H20%/L20% was computed to generate two

groups of countries: one with the highest indicator values

(meaning lower income sharing) and lower values (higher

income sharing). We included only bivariate models due

to the number of countries being small and some of these

variables are collinear.

Results

In the Americas, the overall motorcycle-related mortality

rate was 1.6 per 100,000 in the period 1998–2010. These

rates have been increasing very fast, varying from 0.8 per

100,000 in 1998 to 3.5 per 100,000 in 2010. The trend

analysis showed that the average percentage variation

(APV) from 1998 to 2010 was 12.9% overall. Although

the highest rates in the Americas were found in the South-

ern Cone (2.5 per 100,000) and Andean Area sub-regions

(2.3 per 100,000), the highest increase was reported in the

countries of the Andean sub-region (Ecuador, 78.3%) and

Mesoamerica (Costa Rica, 60.0%).

2 E.M.S. Rodrigues et al.

Dow

nloa

ded

by [

186.

115.

34.2

18]

at 1

1:21

22

Febr

uary

201

4

Page 5: Tendencia de lesiones fatales en motociclitas las americas 1998 2010

Countries with the highest mortality rates were Colom-

bia (3.6 per 100,000), Brazil (2.9 per 100,000), Paraguay

(2.5 per 100,000) and Suriname (2.2 per 100,000). On the

other hand, Chile and Ecuador (0.2 per 100,000) had the

lowest mortality rates. However, the countries with the

greatest increases in rates in the Southern Cone were Chile

and Paraguay. Table 1 summarises the current situation on

mortality deaths and rates as well as the APV by sub-

regions and countries within them. Our rates are different

from the ones reported in the WHO Global Status Report

(World Health Organization, 2009) because the latter report

only computed rates for one year unlike ours that includes

the whole period 1998–2010.

In all the Americas, overall the relative risk (RR) of

dying for men was 7.8 times greater than for women

(95% CI [6.0, 10.2]). Among males, rates varied from

1.4 per 100,000 in 1998 to 6.0 per 100,000 in 2010.

Figure 1 shows mortality rate trends from motorcycle

crashes by sex and for the overall.

The age groups 15 to 24 and 25 to 34 had the highest

risk of dying from motorcycles over the whole study

period and region, and among those less than 15 years of

age is the one with the lowest rate. Notably, those aged 15

to 24 had a risk 24.3 times higher than those less than

15 years (95% CI [18.1, 32.6]). Figure 2 presents the

trends of mortality rates by age groups, where one can see

that all the age groups had increasing rates.

Table 1. Motorcycle-related mortality, rates per 100,000 popand average percent variation (APV), Americas, 1998–2010

Sub-region Country Deaths Rate APV (%)

Southern Cone Brazil 70085 2.9 20.2Paraguay 1691 2.5 35.2Argentina 4316 0.9 14.4Chile 477 0.2 37.4Total 76569 2.5 20.8

Andean Colombia 16557 3.6 1.0Venezuela 2636 1.0 25.6Ecuador 323 0.2 78.3Total 19516 2.3 5.4

Latin Caribbean Cuba 1405 1.4 �4.2Puerto Rico 422 1.2 26.6Total 1827 1.4 20.2

North America United Statesof America

38387 1.3 8.2

Canada 1505 0.6 4.6Total 39892 1.3 8.2

Non-LatinCaribbean

Suriname 109 2.2 50.9

Trinidad andTobago

36 0.3 �1.1

Total 145 0.9 39.3Mesoamerica Costa Rica 857 1.7 60.0

Nicaragua 262 0.4 45.0Panama 151 0.4 26.5Mexico 4851 0.4 12.2Total 6121 0.4 10.0

AMERICAS All countries 144070 1.6 12.9

Figure 1. Motorcycle-related mortality by sex, Americas rate per 100,000.Source: Pan American Health Organization, Health Information and Analysis, Mortality database May, 2012.

International Journal of Injury Control and Safety Promotion 3

Dow

nloa

ded

by [

186.

115.

34.2

18]

at 1

1:21

22

Febr

uary

201

4

Page 6: Tendencia de lesiones fatales en motociclitas las americas 1998 2010

Table 2 shows the estimated rate ratio, confidence inter-

vals and p-values by sub-region, sex and age

(Mesoamerica, Female and less than 15 years old serve as

the reference, as they have the lowest mortality rates).

Motorcycle-related mortality rate ratios by region were

greater in the Southern Cone followed by the Andean

region, were more common among males, and occurred

most commonly among riders aged 25–34 years. Figure 3

Figure 2. Motorcycle-related mortality by age group, Americas rate per 100,000.Source: Pan American Health Organization, Health Information and Analysis, Mortality database May, 2012.

Table 2. Mortality rate ratios (and 95% confidence intervals) among motorcyclists in the Americas

95% CI

Rate Ratio Inferior Limit Superior Limit p-value

Sub-RegionSouthern Cone 6.3 4.3 9.1 <�0001Andean 5.7 3.9 8.3 <�0001Latin Caribbean 3.1 2.1 4.6 <�0001North America 3.2 2.1 4.7 <�0001Non-Latin Caribbean 3.2 2.0 4.9 <�0001Mesoamerica (reference) – – –

SexMale 7.8 6.0 10.2 <�0001Female (reference) – – –

Age15–24 24.3 18.1 32.6 <�000125–34 26.2 19.6 35.2 <�000135–44 17.5 13.0 23.5 <�000145 þ 9.3 6.9 12.5 <�000115 � (reference) – – –

4 E.M.S. Rodrigues et al.

Dow

nloa

ded

by [

186.

115.

34.2

18]

at 1

1:21

22

Febr

uary

201

4

Page 7: Tendencia de lesiones fatales en motociclitas las americas 1998 2010

Figure 3. Age-adjusted motorcycle mortality trends by sub-region per 100,000. (a) Andean Region, (b) Latin Caribbean,(c) Mesoamerica, (d) Non-Latin Caribbean, (e) North America, (f) Southern Cone.

International Journal of Injury Control and Safety Promotion 5

Dow

nloa

ded

by [

186.

115.

34.2

18]

at 1

1:21

22

Febr

uary

201

4

Page 8: Tendencia de lesiones fatales en motociclitas las americas 1998 2010

Figure 3. (Continued)

6 E.M.S. Rodrigues et al.

Dow

nloa

ded

by [

186.

115.

34.2

18]

at 1

1:21

22

Febr

uary

201

4

Page 9: Tendencia de lesiones fatales en motociclitas las americas 1998 2010

shows the trends of motorcycles age-adjusted mortality rates

for the countries within each sub-region. Over this period,

Colombia had higher rates than Venezuela and Ecuador in

the Andean Region, Cuba had decreasing rates in the Latin

Caribbean and Costa Rica showed higher rates than Mexico,

Nicaragua and Panama in the Mesoamerican sub-region.

Suriname had greater rates than Trinidad and Tobago in the

Non-Latin Caribbean, the USA reports greater rates than

Figure 3. (Continued)

International Journal of Injury Control and Safety Promotion 7

Dow

nloa

ded

by [

186.

115.

34.2

18]

at 1

1:21

22

Febr

uary

201

4

Page 10: Tendencia de lesiones fatales en motociclitas las americas 1998 2010

Canada, and Brazil had in general greater rates, compared to

Argentina, Chile and Paraguay in the Southern Cone.

Motorcycle crash mortality rates are unevenly dis-

tributed throughout the Americas. Part of the explanation

might be related to differentials in socio-economic char-

acteristics. We also explored this by assessing the rela-

tion between poverty (gross national income – GNI

converted to international dollars using purchasing

power parity rates) as well as how income is distributed

across the population: how income is shared between the

20% richest versus the 20% poorest families of a coun-

try. Table 3 shows that income distribution seems to be

more associated to mortality rates than income levels:

countries with better income distribution tend to have

lower age-adjusted mortality rates, with a mean mortal-

ity rate 2.3 times higher among the poorest. Table 4

shows the association between motorcycle-related mor-

tality and selected socio-economic indicators. Results

suggest that countries that are poorer tend to have greater

rates of motorcycle fatalities as well as countries that

have more inequalities as measured by the percentage of

share of income by the highest and lowest 20% of the

population.

Discussion

To the best of our knowledge, this is the first paper to

show the overall status of motorcycle fatalities over a

period of time for the entire region of the Americas. In

this region overall, motorcycle-related fatalities have been

steadily increasing in the last few years. Despite this, there

are important differences in magnitude between countries

with some having alarmingly high rates such as Paraguay,

Brazil and Colombia, while others despite lower rates,

show marked increases in fatalities. For the majority of

countries in this region, patterns of mortality are similar

to those reported in other studies or from other parts of the

globe. Young males are the most affected and most deaths

occur in urban settings (Agnihotri & Joshi, 2006; Chi &

Wang, 2007).

Our analysis has some limitations. First, it relies on

country-reported information and many countries have

different systems. Mortality rates may be underestimated

due to data quality problems such as the proportion of

deaths that have not been registered, and the proportion of

injuries-related deaths of unknown intention.

Our data are country-based and consequently miss any

detailed information within country that might provide

additional clues about where motorcycle fatalities are

higher or lower. We used a series of economic indicators

Table 3. Age-adjusted motorcycle mortality rates per 100,000pop by income and shared income among countries with avail-able information for these variables (2000–2010)

Country (a)H20%/

L20% (b)GNI

($ ppp) (c)MortalityRatex

Meanmortality

rate

United States ofAmerica

8.40 40,650 1.30

Costa Rica 12.80 8020 1.70Mexico 12.80 11,480 0.30Venezuela 14.00 8660 1.00Nicaragua 14.40 2090 0.40Chile 14.95 10,350 0.20Argentina� 15.90 9120 0.90 0.84Ecuador 17.40 5860 0.20Suriname 18.60 5250 2.20Paraguay 19.10 3660 2.30Brazil 23.00 7830 2.70Panama 23.95 7820 0.40Colombia 24.05 6600 3.60 1.97

(a) Countries sorted from lowest to highest indicator value (lower valuesindicate better income sharing)(b) Percentage of income sharing (poorest and richest 20% of population)(c) GNI ($ ppp) is gross national income converted to international dol-lars using purchasing power parity rates. An international dollar has thesame purchasing power over GNI as a US dollar has in the United States.(x) Mortality rate per 100,000 in period 1998–2010.(�) Median value of percentage share of income (poorest and richest 20%of population)

Table 4. Association of mortality rate ratios and 95% confidence intervals among motorcyclists in relation to selected socio-economicindicators

95% CI

Covariate Rate Ratio Inferior Limit Superior Limit p-value

H20%/L20%Lower Income Sharing 2.4 1.1 5.2 0.0308Higher Income Sharing (reference) - - -

GNI (�)Lower income 1.5 0.4 5.4 0.5077Upper middle income 1.5 0.6 3.5 0.3484High income (reference) - - -

(�) Based on the income group classification developed by the World Bank:Lower income¼ GNI $3,975 or lessUpper middle income¼ GNI $3,976–12,275High income ¼ GNI $12,276 or more

8 E.M.S. Rodrigues et al.

Dow

nloa

ded

by [

186.

115.

34.2

18]

at 1

1:21

22

Febr

uary

201

4

Page 11: Tendencia de lesiones fatales en motociclitas las americas 1998 2010

as proxies for social conditions in the country that might be

modulating changes in motorcycle fatalities. At an ecologi-

cal level for example, we found that measures of low

income distribution or higher inequalities were related to

mortality rates, more than income levels per capita: coun-

tries with better income sharing had the lowest mortality

rates. Finally, we could not include information from all

countries, as some of the data coming from some nations is

non-existent or not reliable enough to extrapolate to the

entire country. Despite these shortcomings, we believe this

study shows differences within the region of the Americas

as well as important economic differences related to motor-

cycle mortality and overall trends of motorcycle-related

deaths in several countries of this region.

While the economic situation in several richer coun-

tries has been stagnant in the last five years, Latin Amer-

ica has experienced during the same period economic

growth that has contributed to an overall reduction in pov-

erty indexes and an increase in wealth (World Bank

Group, 2011). These improvements however, have not

been equal among different nations and some have fared

better than others.

Parallel to these economic changes, increases in

motorcycle fatalities have also been greater in Latin

America relative to North America. One consequence of

economic growth is increased motorisation. With

increased wealth and reduced poverty, there is evidence

that populations experience shifts in modes of transporta-

tion as they acquire more means to purchase certain prod-

ucts (Chi & Wang, 2007). As countries become motorised

and populations acquire more economic means, a percent-

age of the population shifts from pedestrians and bicy-

clists to motorcyclists, or from motorcyclists to

automobile drivers.

In addition, economic growth is associated with

increased demands from transport infrastructure, and

mobility becomes a basic factor for satisfying economic

needs (Chi & Wang, 2007). More demand or use of

motorcycles and automobiles has increased the pressure

on urban infrastructures (E. Vasconcellos, 2008). This fur-

ther complicates mobility issues as more motorcycles are

competing for space used by automobiles and potentially

further exacerbating risks of injury, and mortality among

riders. In Latin America, the rapid growth of cities and

urban populations has considerably outpaced the develop-

ment of urban transport infrastructures and as a conse-

quence mobility in many large cities has been seriously

compromised. To address this, many cities have passed

legislation aimed at curbing large motor pools mostly by

restricting access to urban areas. These strategies include

limiting the use of automobiles on selected days based on

the license plate registration numbers (E. A. Vasconcellos,

2012). Such a strategy initially used in Mexico City

though for controlling air pollution, is now widely spread

through the region to address mobility. However, in

countries like Colombia, some of these measures do not

apply to motorcycle riders. In this country, to circumvent

these measures, people have either opted to buy another

vehicle, which they use when the other one has restric-

tions, or buy motorcycles, for which mobility restriction

legislation does not apply. A result of this is that popula-

tions with lesser resources are buying motorcycles for the

first time (da Fonseca Holz & Lindau, 2009; E. A. Vas-

concellos, 2012), and individuals with more resources are

also buying these and other vehicles to circumvent mobil-

ity restrictions. Added to this, are the increasing costs of

public transportation that hinder access to work for popu-

lations with the least socio-economic resources (de �AvilaGomide, 2004).

In cities with large levels of congestion, motorcycles

are used in delivery services, as mototaxis, and for moto-

freight (Silva et al., 2011). Groups working in delivery

services in Brazil are known as motoboys who tradition-

ally work under time pressure, and in poor and unsafe

conditions leading to a large increase in motorcycle

crashes (E. Vasconcellos, 2008). Mototaxi service offer

has also increased and in Brazil legislation was passed to

regulate this service almost a decade ago (Barros Loren-

zetti, 2003). Data from this country shows that mototaxis

are now offered in 90% of the country’s towns and 50%

of the major cities (Instituto Brasileiro de Geografia e

Estatistica, 2009). Motorcycle types and types of users

might also have different risks. This is an area of study

that will require further research in Latin America espe-

cially because it can have direct implications among cer-

tain occupations or in some regions.

Research has shown that excessive automobile depen-

dence can reduce economic productivity, and policy

reforms that improve mobility management by reducing

per capita vehicle travel can increase transport system

efficiency (Litman, 2010). Motorcycles seem to have

some advantages for urban mobility because of their size

however they are perhaps the most dangerous type of

motor vehicle because of their inherent lack of protection

for users.

While this study provides no evidence that these eco-

nomic issues are in fact driving such increases, it shows

the important increase of mortality risk in the region of

the Americas among motorcycle riders in a short period

of time and calls for much-needed research on the human,

public health, transportation and social-economic costs

associated with motorcycle injuries. The PAHO Plan of

Action on Road Safety (Pan American Health Organiza-

tion, 2011) and the Road Safety Decade of Action (World

Health Organization, 2009) reports highlight relevant

interventions that can be considered in order to slow or

reverse the increasing trend of motorcycle injury mortal-

ity. Examples of such measures could include the devel-

opment and implementation of motorcycle safety

standards regulations.

International Journal of Injury Control and Safety Promotion 9

Dow

nloa

ded

by [

186.

115.

34.2

18]

at 1

1:21

22

Febr

uary

201

4

Page 12: Tendencia de lesiones fatales en motociclitas las americas 1998 2010

Implications for safety promotion and public policy

The highlighted socio-economic scenario is further

affected by insufficient legislation and enforcement of

helmet use. Less than half (40.6%) of the countries in this

region have an adequate helmet law implying that helmets

should be worn by all passengers of all ages, for all engine

types of motorised two wheelers, on all roads, and with

helmets required to meet specific safety standards. On a

PAHO/WHO generated scale of 0–10 where zero repre-

sents no enforcement and 10 is full enforcement, the aver-

age regional helmet law enforcement is 5.1/10 while

enforcement of speeding laws was reported to be low,

with a value of 3.7/10 (Hijar et al., 2012).

It is imperative for the region of the Americas to docu-

ment more clearly what social and economic costs are

associated with increased motorcycle-related mortality

and morbidity and what are the benefits of managing these

modal changes within countries as well as throughout the

region. Consequently legislative frameworks will likely

need to address issues going beyond helmet use, speed lim-

its and motorcycle driver’s licensing procedures to include

motorcycle industry responsibilities and occupational

safety provisions for workers. Both legislative frameworks

as well as infrastructure characteristics need to respond to

these challenges so as to reduce morbidity and mortality

amongst one of the most productive sectors of population.

References

Agnihotri, A.K., & Joshi, H.S. (2006). Pattern of road trafficinjuries: one year hospital-based study in Western Nepal.International Journal of Injury Control and Safety Promo-tion, 13(2), 128–130.

Ahmad, O., Boschi-Pinto C.A., Murray, C., Lozano, R., & Inoue,M. (2001). Age Standardization of Rates: A New WHO Stan-dard. Geneva: World Health Organization.

Barros Lorenzetti, R.S. (2003). A regulac~ao do servico demotot�axi. In C. o. Representatives (Ed.), Urban Develop-ment, Transit and Transportation. Brasilia: Chamber ofRepresentatives.

Beck, L.F., Dellinger, A.M., & O’Neil, M.E. (2007). Motor vehi-cle crash injury rates by mode of travel, United States: usingexposure-based methods to quantify differences. AmericanJournal of Epidemiology, 166(2), 212–218.

Chandran, A., Sousa, T.R., Guo, Y., Bishai, D., & Pechansky,F. (2012). Road traffic deaths in Brazil: rising trends inpedestrian and motorcycle occupant deaths. Traffic InjuryPrevention, 13(Suppl 1), 11–16.

Chi, G. B., & Wang, S.Y. (2007). Study on the secular trend ofroad traffic injuries and its influencing factors in China.Zhonghua liu xing bing xue za zhi ¼ Zhonghua liuxingbing-xue zazhi, 28(2), 148–153.

Crandon, I.W., Harding, H.E., Cawich, S.O., McDonald, A.H.,& Fearron-Boothe, D. (2009). Motorcycle accident injuryprofiles in Jamaica: an audit from the University Hospital ofthe West Indies. International Journal of Injury Control andSafety Promotion, 16(3), 175–178.

da Fonseca Holz, R., & Lindau, L.A. (2009). Panorama interna-cional do uso e operac~ao de motocicletas. Porto Alegre:

Pol�ıtica de Transporte e Inclus~ao Social 1, (3). Laborat�oriode Sistemas de Transportes, LASTRAN, Programa de P�os-Graduac~ao em Engenharia de Produc~ao, PPGEP, Universi-dade Federal do Rio Grande do Sul, UFRGS.

de �Avila Gomide, A. (2004). Regulac~ao economica e organ-izac~ao dos servicos de transporte p�ublico urbano emcidades brasileiras : Estudos de caso : Relat�orio final. Brasi-lia, Ipea: Minist�erio das Cidades.

Espitia-Hardeman, V., Velez, L., Munoz, E., Gutierrez-Martinez, M.I., Espinosa-Vallin, R., & Concha-Eastman, A.(2008). [Impact of interventions directed toward motorcy-clist death prevention in Cali, Colombia: 1993–2001]. Saludpublica de Mexico, 50, Suppl 1, S69–77.

Franco Arias, C. (2010a). Auditor�ıa en seguridad vial. Ambienteseguro: Intervenciones para prevenci�on de atropellamientos(ASIPA): Estudios viales. Cuernavaca: Instituto Nacional deSalud Publica.

Franco Arias, C. (2010b). Auditor�ıa en seguridad vial. Ambienteseguro: Intervenciones para prevenci�on de atropellamientos(ASIPA): Problem�atica y propuestas. Cuernavaca: InstitutoNacional de Salud Publica.

Gawryszewski, V.P., Coelho, H.M., Scarpelini, S., Zan, R., Jorge,M.H., & Rodrigues, E.M. (2009). [Land transport injuriesamong emergency department visits in the state of Sao Paulo,in 2005]. Revista de Saude Publica, 43(2), 275–282.

Hazen, A., & Ehiri, J.E. (2006). Road traffic injuries: Hiddenepidemic in less developed countries. Journal of theNational Medical Association, 98(1), 73–82.

Hertz, E.S. (1989). The effect of helmet law repeal on motorcy-cle fatalities. A four year update. National Highway TrafficSafety Administration. Research Notes, September, 1–4.

Hijar, M., Perez-Nunez, R., Inclan-Valadez, C., & Silveira-Rodrigues, E.M. (2012). Road safety legislation in theAmericas. Revista Panamericana de Salud Publica ¼ PanAmerican Journal of Public Health, 32(1), 70–76.

Instituto Brasileiro de Geografia e Estatistica. (2009). Pesquisasobre oferta de transporte p�ublico nos munic�ıpios brasileiros.Brasilia: Instituto Brasileiro de Geografia e Estatistica.

Instituto de Pesquisa Economica Aplicada. (2006). Impactossociais e economicos dos acidentes de transito nas rodoviasbrasileiras. Brasilia: Departamento Nacional de Transito.

Litman, T. (2010). Evaluating transportation economic develop-ment impacts. Understanding how transport policy and plan-ning decisions affect employment, incomes, productivity,competitiveness, property values and tax revenues (p. 99).Victoria Transport Policy Institute, August 10. Retrievedfrom http://www.vtpi.org/econ_dev.pdf

Muelleman, R.L., Mlinek, E.J., & Collicott, P.E. (1992). Motor-cycle crash injuries and costs: Effect of a reenacted compre-hensive helmet use law. Annals of Emergency Medicine, 21,266–272.

National Highway Traffic Safety Administration. (2011). Deter-mining estimates of lives and costs saved by motorcycle hel-mets. Washington, DC: U. S. Dept. of Transportation.

Naumann, R.B., Dellinger, A.M., Zaloshnja, E., Lawrence, B.A.,& Miller, T.R. (2010). Incidence and total lifetime costs ofmotor vehicle-related fatal and nonfatal injury by road usertype, United States, 2005. Traffic Injury Prevention, 11(4),353–360.

Pan American Health Organization. (2008). Health informationand analysis – health situation in the Americas: Basic indica-tors. Washington, DC: Pan American Health Organization.

Pan American Health Organization. (2009). Regional statusreport on road safety in the Americas. Washington, DC: PanAmerican Health Organization.

10 E.M.S. Rodrigues et al.

Dow

nloa

ded

by [

186.

115.

34.2

18]

at 1

1:21

22

Febr

uary

201

4

Page 13: Tendencia de lesiones fatales en motociclitas las americas 1998 2010

Pan American Health Organization. (2011). Plan of action onroad safety. Washington, DC: Pan American HealthOrganization.

Peden, M., Scurfield, R., Sleet, D., Mohan, D., Hyder, A.A., Jara-wan, E., & Mathers, C. (Eds.). (2004). World Report on RoadTraffic Injury Prevention. Geneva: World Health Organization.

Silva, E.R., Cardoso, B.C., & Santos, M.P.S. (2011). O aumento dataxa de motorizac~ao de motocicletas no Brasil. Revista Brasi-leira de Administrac~ao Cient�ıfica, Aquidab~a, 2(2), 50–62.

Vasconcellos, E. (2008). O custo social da motocicleta no Brasil.Revista dos Transportes Publicos, 119(20), 127–142.

Vasconcellos, E.A. (2012). Road safety impacts of the motorcy-cle in Brazil. International Journal of Injury Control andSafety Promotion. doi: 10.1080/17457300.2012.696663.

Villaveces, A., Cummings, P., Koepsell, T.D., Rivara, F.P.,Lumley, T., & Moffat, J. (2003). Association of alcohol-related laws with deaths due to motor vehicle and

motorcycle crashes in the United States, 1980–1997. Ameri-can Journal of Epidemiology, 157(2), 131–140.

Watson, G.S., Zador, P.L., & Wilks, A. (1980). The repeal ofhelmet use laws and increased motorcyclist mortality in theUnited states, 1975–1978. American Journal of PublicHealth, 70, 579–585.

World Bank Group. (2011). A Break with history: Fifteen yearsof inequality reduction in Latin America (pp. 1–29).Washington, DC: World Bank Group.

World Health Organization. (2009). Global status report on roadsafety: A time for action. Retrieved from http://whqlibdoc.who.int/publications/2009/9789241563840_eng.pdf

Zentner, J., Dellinger, C., Adkins, W.E., & Greene, J. (1995).Nurse practitioner provided primary care: managing healthcare costs in the workplace. AAOHN Journal; Official Jour-nal of the American Association of Occupational HealthNurses, 43(1), 52–53.

International Journal of Injury Control and Safety Promotion 11

Dow

nloa

ded

by [

186.

115.

34.2

18]

at 1

1:21

22

Febr

uary

201

4