Injury patterns among commercial motorcycle users attending Kitale level IV district hospital, Kenya

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2 Prime Journal of Social Science (PJSS) ISSN: Vol. 3(7), pp , July xx, Prime Journals Full Length Research Paper Injury patterns among commercial motorcycle users attending Kitale level IV district hospital, Kenya 1 Peter Kiteywo Sisimwo, 2 Peter Kabanya Mwaniki and 3 Christine Bii 1 Jomo Kenyatta university of agriculture and technology, College of Health Sciences, P.O. Box Kitale, Kenya. psisimwo@yahoo.com; psisimwo@gmail.com 2 Jomo Kenyatta university of agriculture and technology, college of health sciences, Kenya 3 Kenya medical research institute, centre for medical research, Nairobi, Kenya Accepted 14 th July, 2014 The rise in the use of commercial motorcycles in Kenya has been associated with increased injury rates. Between 2004 and 2009, motorcycle injuries increased at a rate of 29 %. In some hospitals, commercial motorcycle users have become the predominant road user category injured. We carried out a descriptive cross sectional study to determine the socio demographic characteristics, injury patterns and mechanism leading to commercial motorcycle crash injuries at Kitale district hospital. 371 Commercial motorcycle trauma patients were recruited consecutively between 1 st August 2013 and 31 st October The data captured included demographics; injury patterns, mechanism of injury, helmet use and Glasgow coma scale. Data collection was done using a pre-tested, coded questionnaire. Frequencies, mean and chi-square was employed in the analysis. Analysis was done using SPSS V.20. Results were considered significant at α=0.05. Commercial motorcycle injury patients formed 39.4% of all road traffic injury admissions. 70.1% were males and median age was 30 years. Pattern of injuries sustained by victims included head and neck injury 40%, lower extremity injury 39.9% and chest injury 8.2%. Motorcycle riders (45.1%) and passengers (38.9%) without a helmet during the crash sustained severe head injuries ( 2 = , P<0.001). Surgical intervention was indicated for 63.8% of the inpatients. 70% of patients with head injuries were assessed as having Glasgow coma scale of 9-12, 26% GCS of and 7% GCS of 3-8. Motorcycle versus vehicle was the most common mechanism of motorcycle crash injury 45.6%. Head injuries and lower extremity injuries accounted for the major proportion of injuries sustained by commercial motorcycle users. Non helmet use was associated with increased risk of head injuries. Morbidity can be mitigated by encouraging use of protective gear like helmets and encouraging enforcement of traffic laws. Key words: Injury patterns, severity, commercial motorcycle injuries, Kenya INTRODUCTION Road traffic injuries contribute significantly to the burden of disease and mortality throughout the world, but particularly in developing countries (Ameratunga et al., 2006). Currently Road traffic injuries are ranked ninth globally among the leading causes of disability adjusted life years lost. It has been predicted that by 2020, they will rank as high as third among causes of disability adjusted life years (DALYs) lost (Peden et al., 2000). It has been observed that recently all over the world, motorcycle collisions account for a considerable rate of morbidity and mortality due to road traffic crashes (Lin et al., 2009). In America for instance recent literature reported that more people than ever are purchasing motorcycles, particularly more middle aged men (NHTSA, 2006). Motorcycle is a most dangerous mode of transportation than automobile because there is no structure to protect the rider during a crash. When compared as per mile traveled it was realized that drivers are 21 times more likely to be killed on a motorcycle than in an automobile (NHTSA, 2006). The increase of Motorcycle crash has been reported in a number of African countries. In Nigeria for instance motorcycle crashes were responsible for 54% of all injuries seen in one teaching Hospital (Madubueze et al.,

3 807 Prim. J. Soc. Sci. 2006). While in Uganda motorcycle crashes were responsible for 25% of all RTI seen at Mulago Teaching Hospital (Naddumba, 2004). The motorcycle, commonly called bodaboda in Uganda and Kenya (Galukande et al., 2004) and Okada in Nigeria (Oluwadiya et al., 2004) has recently become increasingly popular in Kenya as a means of commercial transport. Their operation is characterized by non-helmet use by riders and passengers, passenger overload, lack of valid licensing, over speeding and reckless driving, poor regulation and law enforcement and possible use of alcohol and drugs (Museru and Leshabari 2002). The scarcity of existing data on commercial motorcycle injuries in this environment despite morbidity and mortality resulting from motorcycle crashes necessitate a further look into the injury patterns, severity and mechanism influencing the occurrence of such crashes. Studying the injury pattern of these motorcyclists will reveal the burden of the problem, as deaths and injuries due to road traffic crashes have not really been seen as a matter of public health importance. This was a descriptive cross sectional study of injuries among commercial motorcycle users presenting at Kitale district hospital. Research objectives 1. To determine the socio demographic characteristics of patients with commercial motorcycle crash injuries attending Kitale level IV district hospital. 2. To determine the injury patterns and severity among commercial motorcycle crash injury patients attending Kitale level IV district hospital. 3. To describe the mechanism leading to commercial motorcycle crash injuries among patients attending Kitale level IV district hospital. METHODS This was a descriptive cross-sectional study of patients with commercial motorcycle crash injuries of all age groups and gender presenting at the Accident and Emergency (A&E) department of Kitale level IV District Hospital. Kitale level IV district hospital provides Accident and Emergency services and its Government sponsored. Trauma patients are first resuscitated and managed at the A&E Department according to the Advanced Trauma Life Support (ATLS) principles and then admitted to the admitting surgical firm. The study population comprised victims of commercial motorcycle crashes presenting at the Accident and Emergency department between 1 st August 2013 and 31 st October All victims of commercial motorcycle crash injuries presenting at the accident and emergency department were eligible for the study. At presentation, patients or their conveyers were interviewed by research assistants according to the details provided on a proforma. The data collected were patient s bio data, the injury sustained, mechanism of the crash injury, pre hospital transportation, body region injured, radiological findings, setting of the crash, condition of the road, collision type and use of helmet. The personal status during the crash was identified whether he/she was the rider, passenger and pedestrian. The fate of the subject whether discharged in good condition, admitted to the wards, referred or died was documented. Using the Fischer s exact test the minimum sample size calculated was 371. Data cleaning and validation was performed using SPSS version 20. Descriptive statistics such as mean, standard deviation, range and frequency proportions was performed. Pearson s chi square was used to test for the significance of association between dependent variable and independent variables. The level of statistical significance was set at P < Binary logistic regression was used to adjust for confounding. RESULTS During the study period 942 cases of road traffic injuries were seen at the A&E department. Commercial Motorcycle traffic injuries accounted for 39.4% of all traffic injuries. 371 commercial motorcycle crash related injury patients participated in the study. 259(69.8%) were males and the mean age (in years) was 30.7(SD ± 13). The youngest age reported was 3 years and the oldest was 80 years, with a range of 77 years. The educational level of victims revealed that of the 167 riders, 106 (44%) had primary level of education. 40 (34%) of passengers had at least secondary education with 12 (100%) having tertiary education. The occupational status revealed that 163 (43.9%) of the victims were commercial motorcyclists, 65 (17.5%) were students, and 40 (10.8%) were farmers (Table 1). Motorcycle versus vehicle was the most reported mechanism of the motorcycle crash injuries 175(45.6%). Motorcycle versus motorcycle was reported by 90(23.4%) patients, motorcycle versus pedestrian 147 (39.6%) and motorcycle versus bicycle formed 9.9% of the cases reported (figure 1). As regards the anatomical location of injuries, Hundred and forty seven (39.9%) had head and neck injuries and a similar proportion were injured at the lower extremity (figure 2). Majority of those who did not have helmet at the time of the crash had head injuries as compared to those who had helmet ( 2 = , P<0.001). All the patients with severe head injury did not wear helmet at the time of injury. Majority of the patients were treated as in-patients 317(85.7%). Among those treated as outpatients, 38(73.1%) were done minor surgery and 3(5.8%) received radiology and drug prescription services. Among the inpatients, 201(63.8%) had major surgery and 73(23.2%) had radiological investigations. Most of the injuries sustained by victims were 259(70%) moderate, 25(6.8%) severe, 1(0.3%) critical and 1(0.3) fatal (Figure 3). On arrival at the hospital,

4 Sisimwo et al., 808 Table 1: Socio-demographic characteristics of the respondents Characteristic Rider (%) Passenger (%) Pedestrian (%) Total (%) Gender Male Female 165(64) 2(1.8) 67(26) 77(68.8) 26(10.1) 33(29.5) 259 (69.8) 112 (30.2) Religion Christian Muslim Marital status Single Married Divorced Widowed Education level Primary Secondary College Occupation Businessman/woman Motorcyclist Driver Student Farmer Housewife Other 165(45.5) 1(16.7) 60(38) 107(51.2) 106(44) 61(52.1) 1(2.1) 161(98.8) 1(1.6) 1(2.5) 3(12) 141(38.8) 3(50) 57(36.1) 84(40.2) 2(100) 1(100) 92(38.2) 40(34.2) 12(100) 31(66) 1(0.6) 3(75) 33(51.6) 35(87.5) 19(79.2) 21(84) 57(15.7) 2(33.3) 41(25.9) 18(8.6) 43(17.8) 16(13.7) 15(31.9) 1(0.6) 1(25) 30(46.9) 4(10) 5(20.8) 1(4) 365 (98.4) 6(1.6) 159(42.9) 209(56.3) 2(0.5) 1(0.3) 242(65.2) 117(31.5) 12(3.3) 47(12.7) 163(43.9) 4(1.1) 65(17.5) 40(10.8) 24(6.5) 25(6.7) Figure1: Mechanism of motorcycle crash injury 240(64.7%) patients with head injury were assessed as having Glasgow coma scale of between 9-12 moderate injury and 29(7.8%) was between 3-8 severe injuries. There was a significant relationship between the category of road user and severity of the crash injury (p<0.001). 49 (29.3%) of motorcycle riders had severe injuries, 9 (6.2%) of passengers had severe injuries while 2 (3.4%) of pedestrians had severe injuries (Table 2). Similarly, there was a significant relationship between age-group and severity of the crash injury (p=0.007). 21 (21.2%) Motorcycle injury victims in the age group suffered severe injuries. 1(10%) of those in the age group >60 suffered severe injury as indicated in table 3. Table 4 shows that 28 (16.8%) of the motorcyclists were found to have had formal training before riding. The use of personal protective devices was generally poor as only 32% of riders and passengers use crash helmets, 2 (0.5%) wear special shoes, but it was found that 91% of them wear protective clothing basically to protect them from cold. In contrast to their use of protective devices, the participants tended to pay attention to safety devices on their motorcycles. The majority reported that they ensured that the indicator lights and head lamps 295 (82.2%) were in proper working conditions.

5 809 Prim. J. Soc. Sci. Figure 2: Anatomical/Site of injury Figure 3: Abbreviated injury score Table 2: Relationship between category of road user and severity Road user Minor Moderate Severe Motorcycle rider 12(7.2%) 106(63.5%) 49(29.3%) Passenger 8(5.6%) 127(88.2%) 9(6.2%) Pedestrian 32(54.2%) 25(42.4%) 2(3.4%) 2 = , p<0.001 Table 3: Relationship between age-group and severity of crash injury Age-group (yrs) Severity of crash injury Minor Moderate Severe <25 29(23.6% 79(64.2%) 15(12.2%) (12.2%) 66(66.7%) 21(21.2%) (7.2%) 106(76.3%) 23(16.5%) >60 1(10%) 8(80%) 1(10%) 2 =17.678, p=0.007

6 Sisimwo et al., 810 Table 4: Risk behaviors and occurrence of crashes among commercial motorcycle users Characteristics Frequency Percentage Training before riding % Use of protective devices Use of crash helmet % Wearing of protective clothing % Special shoes 2 0.5% Proper working conditions of motorcycle safety devices Flashing lights % Use of alcohol Clinical suspicion % Declined blood test 6 1.6% Not assessed % Alcohol content was not assessed for 78.9% of riders, passengers and pedestrians, however there was clinical suspicion in 59 (15.4%) of the victims. 6 (1.6%) of the victims declined to be tested for blood alcohol levels. DISCUSSIONS Road transportation plays an important part in a society for the movement of not only people but also of goods. The consequences of road crashes cannot be overemphasized as it leads to morbidity, mortality and increased economic cost in terms of managing injuries and hospitalization. Due to the relative cost of purchase and ease of maintenance in comparison to motor vehicles, the use of motorcycles in Kenya as a means of transportation is seen as a cheap alternative in the movement of people and goods both on a commercial and private basis. In addition the commercial motorcycle operators claim that the motorcycles are fuel efficient in the light of frequent fuel scarcities, and are able to navigate poor network of roads with the frequent attendant traffic congestion both in the cities and rural areas. The majority of motorcycle crash injury victims were of the age between 21 and 30 years. This is similar to other studies where the majority of patients involved in motorcycle crash were aged between 20 and 29 years (Naddumba, 2004). In contrary two studies done elsewhere reported the majority of motorcycle crash injury victims to be less than age of 20 years (Oluwadiya et al., 2004). The reason why the youth are involved in commercial motorcycle could be explained by the fact that at this age group majority are engaged in productive activities predisposing to risks of being involved in road traffic crashes. In this study more males than females were commercial motorcycle riders. Similar findings have been reported elsewhere (NHTSA, 2006). This could be explained by the fact that there are more male riders than female. In this study the majority of motorcycle crash injuries were found to be riders. Similar findings were reported elsewhere where they found that 41.0% to 62.0% of motorcycle crash injury victims were riders (Solagberu et al., 2006). This shows that the riders constitute the majority of motorcycle crash injury victims reporting to hospitals. Therefore this particular group requires a special attention when planning strategies to prevent motorcycle crashes. In this study half of victims had primary education and below. This perceived low level of literacy could be due to their inability to appreciate safety messages and codes. This supports another study in which motorcyclist with higher level of education were found to practice safety codes more regularly (Amoran et al., 2006). In addition, illiterate riders may not be able to interpret road signs thus contributing to road crashes. The most commonly sustained injuries were to the head followed by injuries of the lower and upper extremity as reported previously from other populations (Peden et al., 2004). The vulnerability of the extremities in particular the lower limbs could be due to a number of factors such as anatomical location, lack of protectors on the extremity and poor assembly of rear wheel. Some studies have however reported head injury as the most frequently occurring injury among motorcyclists. A study to asses motorcycle injuries in north-central Nigeria, reported that head injury (40.1%) was the most frequently occurring injury followed closely by extremity injuries (38.1%). None of the patients wore protective helmet (Nwadiaro et al., 2011). The increased risk of serious head injury in the absence of helmet wearing as has been documented previously and our study reinforces these findings in a developing world context (Liu et al., 2008). In this study there was a significant relationship between the category of the road user and severity of the injuries (p<0.001). Higher percentage of severe cases was among the motorcycle riders. However in a study of road traffic injuries in Western Maharashtra, no positive correlation existed between category of road user and severity of injury (Patil et al., 2008). This could be attributed to differences in areas of study as well measurement scales of the study variable. The commonest cause of motorcycle crash was collision with a vehicle. Vehicles have been reported to contribute majority of motorcycle accidents mainly due to their inability to detect or recognize them in traffic

7 811 Prim. J. Soc. Sci. (Solagberu et al., 2006). This shows that probably cooperation, awareness and concern for others and good riding and driving habits are essentials among all road users. The study also found that the pedestrian (39.6%) remains a vulnerable group to motorcycle crash similar to what has been reported elsewhere (Naddumba, 2004). The motorcycle-vehicle and motorcycle-pedestrian collisions occur commonly because the majority of the riders often ignore safety measures, making them more vulnerable to crashes with other motorized vehicles (Oluwadiya et al., 2004). In addition, the absence of pedestrian walkways in most of the roads in Kenya has increased the vulnerability of pedestrians to all motorized vehicles. Among the motorcycle crash riders that participated in the study a smaller percentage 28 (16.8%) had training before riding a motorcycle. An unlicensed or improperly licensed rider is a factor that has been associated with motorcycle fatalities. In 2007, 26% of motorcyclists involved in fatal crashes did not have a valid motorcycle license, compared to 13% of drivers of passenger vehicles who were not properly licensed (NHTSA, 2006). CONCLUSIONS Commercial motorcycle crash is a major cause of road traffic injury among victims attended to at Kitale level IV hospital. The youth in their reproductive age group were the most involved in commercial motorcycle crashes. The pedestrians, riders and their passengers were commonly injured in motorcycle crashes. The majority of the injuries involved the lower extremity and head. Commercial motorcycle riders and passengers without helmets at the time of crash suffered severe head injuries. Larger proportion of the riders didn t undergo formal training before riding a motorbike. Motorcycle and motor vehicle collision was the commonest recorded mode of crash accounting for majority of the injuries. Recommendations 1. Commercial motorcycle riders to undergo comprehensive pre-riding course and be tested by traffic police before possessing a riding license. 2. Commercial motorcycle riders and their passengers to wear helmet. 3. Provision of educational and training programs aimed at improving road user behavior among the general public. 4. Further studies should be done on the role of alcohol and substance use among commercial motorcycle riders and crash occurrence. University of Agriculture and Technology for facilitating the carrying out of the study. REFERENCES Ameratunga S HM, Norton R (2006). Road traffic injuries: confronting disparities to address a global health problem. Lancet 367: Amoran OE, Owoaje E, Giwa OA, Gbolahan OB (2006). Road safety practices among commercial motorcyclists in a rural town in Nigeria: implications for health education. International Quarterly of Community Health Education. 24(1): Galukande M, Jombwe J, Fualal J, Gakwaya A, (2009). Bodaboda injuries a health problem and a Burden of Disease in Uganda: A tertiary Hospital survey. East and Central African Journal of Surgery 14: Lin MR, Kraus JF (2009). A review of risk factors and patterns of motorcycle injuries. Accident Analysis Preview July; 41(4): PubMed PMID: Liu B, Ivers R, Norton R, Boufous S, Blows S, Lo S (2008): Helmets for preventing injury in motorcycle riders. Cochrane Database Syst Rev 2008:CD Madubueze CC, Chukwu CO, Omoke NI, Oyakhilome OP, Ozo C (2006). Road traffic injuries as seen in a Nigerian teaching hospital. Int Orthop. Jul 11. PubMed PMID: Museru LM, Leshabari MT, (2002). Road traffic accidents in Tanzania: A 10-year epidemiological appraisal. East and Central African Journal of Surgery 7: Naddumba EK, (2004). A cross sectional retrospective study of boda boda injuries at Mulago Hospital in Kampala, Uganda. East Cent Afr J Surg; 9:44-7. National Highway Transport Safety Authority (2006). Recent trends in fatal motorcycle crashes: An update: Washington: US Department of Transportation. Nwadiaro HC, Ekwe KK, Akpayak IC, Shitta H, (2011). Motorcycle injuries in north-central Nigeria. Niger J Clin Pract. 14:186-9 Oluwadiya KS, Oginni IM, Olasinde AA, Odu OO, Olakulehin OA, Olatoke SA, (2004). Motorcycle limb injuries in a developing country. West African Journal of Medicine. 23: Patil SS, Kakade RV, Durgawale PM, Kakade SV, (2008). Pattern of road traffic injuries: A study from western Maharashtra. Indian Journal of Community Medicine. 33: Peden M, Scurfield R, Sleet D, Mohan D, Hyder AA, Jarawan E, Mathers C, (2004): World report on road traffic injury prevention. Geneva: World Health Organization Peden MK, Krug E, (2000). Injury: a leading cause of the global burden of disease. Geneva: WHO; The injury chart book. Solagberu BA, Ofoegbu CK, Nasir AA, Ogundipe OK, Adekanye AO, Abdur-Rahman LO, (2006). Motorcycle injuries in a developing country and the vulnerability of riders, passengers, and pedestrians. Inj Prev.Aug; 12(4): Acknowledgement We would like to acknowledge the management of Kitale District hospital, ITROMID/ KEMRI and Jomo Kenyatta