Umeå University. Master s Thesis in Public Health. Asonganyi Edwin Nyagwui. Nr 17/2012

Transcription

1 Umeå University Master s Thesis in Public Health Title: Assessing the risk of motorcycle injuries among secondary school students in the Tiko Municipality Major Subject: Public Health Specialization: Epidemiology Asonganyi Edwin Nyagwui Nr 17/2012 Umeå International School of Public Health (UISPH) Department of Epidemiology and Global Health Umeå University SE Building 9B, University Hospital Entrance X5

2 UMEÅ UNIVERSITY Umeå International School of Public Health (UISPH) Department of Epidemiology and Global Health Supervisor: Dr. Yulia Blomstedt, Thesis Author: Asonganyi Edwin Nyagwui, Education Program: Public Health and Specialty in Epidemiology 120 ECTS Session: Spring 2012 Thesis: 30 ECTS Scope: 24,850 words including appendix Date:

3 ASSESSING THE RISK OF MOTORCYCLE INJURIES AMONG SECONDARY SCHOOL STUDENTS IN THE TIKO MUNICIPALITY By: Asonganyi Edwin Nyagwui Master s Thesis in Public Health Supervisor: Yulia Blomstedt (PhD) Umeå University Department of Epidemiology and Global Health May 2012

4 DEDICATION Motorcycle is a wonderful assemblage of highly engineered parts. Parts are designed and intended to work together for your enjoyment and safety. Just like your body, when all the parts are working as planned, everything goes swimmingly! But when parts balk, or worse yet fail; ouch! So you need to care for all your body parts and all your motorcycle parts too as well! Asen To my kid sister EMEAWUNG CYNTHIA NYAGWUI i

5 ACKNOWLEDGEMENT I wish to express my special thanks to all whom in one way or another supported me towards the realization of this project. Since it is not possible to thank you all in person and in public but would take this opportunity to mention some people who deserve special appreciation. I am thankful to God for his wonderful love and care all throughout my studies in Sweden and most especially for providing me with all the help and assistance. You are worthy to be praised. This work is a product of enormous contributions from my supervisor Dr. Yulia Blomstedt. Words cannot express my happiness deep down in me for all the challenges I faced and she stood up for giving me the courage and strength despite her busy scheduled. Special thanks for her unflinching support, advice and comments, especially by taking time to make a detailed review of the thesis. Her constructive criticisms, challenges and her teaching on data analysis using logistic regressions techniques helped me to improve and shape my skills in quantitative research. Our cordial relationship transcended from the academic environment to social interactions; support and attention that made me feel at home while in Umeå, Sweden. I will ever remain indebted to all the staff in the Department of Epidemiology and Global Health for growing me up to the research field throughout my study in Umeå University. Special thanks go to my lecturers especially Dr. Nawi Ng for giving the best knowledge of it kinds in Epidemiology, Associate Professor Lennarth Nystrom for the technical know-how when dealing with biostatistics analysis and Sabina Bergsten in all the administrative supports which has been invaluable. Lastly, to all my PhD friends with whom I shared some experiences in academics and social activities most especially Dr. Felix Kisanga, Dr. Rose Liasser, Dr. Gasto Frumence, Frederic Norström and Fridinah Namatovu. I appreciate all the moments spent with you people and it was great and lovely. There is nothing more in this world than having a lovely and peaceful family. My deepest and heartfelt gratitude goes to the Asonganyi s family, particularly my parents who raised me, took me to the school and taught me the importance of education, otherwise without them I could not have reached where I am today. I thank my brothers and sisters for their spiritual and moral support though we are thousand miles apart. Special thanks goes to my uncle and his wife Mr. and Mrs. Njiaka Michael for their generosity, kindness, solidarity, material and financial assistance to make life easy and comfortable for me as I pursue my studies in Umeå University. This was so great of you people despite the hard times and economic instability. I cannot forget to mention the support of my cousins Roland Fongei Tohnya and Tanyifor ii

6 Manga Tohnya for their continuous guidance, tireless support and cooperation at all stages in my stay in Sweden. I cannot forget to express my sincere thanks to the Ulander s family especially Josef and Charlotte Ulander for making my stay in Umeå hospitable. I really would not know how to thank you all but God Almighty will bear me witness for I felt as if I was in Cameroon. The financial assistance was a great help to comfort me as I carry on my studies in Umeå. The Lord Almighty God blesses my sponsors and I thank them all for the unflinching financial assistant. There is a saying that no man is an island. Leaving Cameroon to study abroad is not easy at all, if not unbearable without friends. I appreciate the support of Che Bernard Longho my roommate for the enormous contributions academically and socially, Nguilefem Azamo, Mr and Mrs Wilfred Azamo, Mr and Mrs Ekellem Conrad, Samuel Cumber. What a true friend indeed! I would like to acknowledge the very significant contributions from my friends who I cannot mention here. I thank the Cameroon Association of Students in Umeå especially Emmanuel Mukumu, Janet Agbor, Okah Peter Okah and Tanila Yvette. Special thanks to my friends most especially Mary-Ann Efesoa, Ngale Fru Njiwah, Ade Ken Rita, Marie-Therese Ngwa Mankaa and Kwende Ernest Ayambang for all their encouragement, prayers and supports to make me acquire the dreams I ever wish in my life. Thanks you all. Lastly, but not the least I appreciate the great cohort of master students in Umeå International School of Public Health class of academic year. It was wonderful being together for these two years of successful studies. The knowledge gathered so far is of great importance and this will help me much in life. I acknowledged the strong bond of friendship despite our differences in gender settings. iii

7 ABSTRACT Background: Injury from motorcycle is a considerable cause of death and disability in the world and is becoming one of the most serious public health problems not only in developed countries but most especially in low and middle-income countries. It is estimated that 5.8 million people died world-wide from motorcycle injuries in 1998, corresponding to a rate of 97.9 per population. Injuries are the leading causes of death in all age groups and for both male and female. Among the first six top 15 leading causes of death in the world for persons aged is due motorcycle injury. Due to the densely populated region in the Tiko municipality, southwest region-cameroon, transportation poses a serious problem. Aim: The aim is to study the risk-factors of the motorcycle related injuries among secondary school students in the Tiko municipality, Cameroon. Methods and Materials: The study was a descriptive cross sectional, carried out among students from years of age in the public and private high schools in the Tiko municipality that were exposed to the risk of motorcycle injuries. The main instrument used for the study was a specially designed close-ended questionnaire. A total of 391 students responded to the survey. The data were computerized using Epidata version 3 and analyzed using STATA version 11. Results: The study showed that on the average, sampled students had a high knowledge about the risk associated with motorcycles accidents and injuries but their practices and safety are poor. The study showed that those who drove motorcycle were highly associated of having accident and injury and it was statistically significant with OR 0.31( ) and p- value (p<0.000). Also, those who lived in the Tiko-Douala road have the likelihood to sustain accidents and injuries and it was statistically significant with OR 3.19 ( ) and p-value (p<0.020) as well. The study also showed that males are more likely to be involved in accident than females. Conclusions: The knowledge of the students was considerable high but their practices were poor. The students were more exposed in motorcycle accident either as drivers or passengers which leads to differences in accident and injury. Majority of the respondents that had injury as a result of accident were passengers. The high probability of accidents and injuries were due to human behaviors. The motorcycle and the environment also contributed to the proportion of accidents and injuries as well. Finally, the Tiko-Douala highway road was associated to students having accidents and injuries. Keywords: Awareness, practice, safety, motorcycle, accident, injury and students iv

8 TABLE OF CONTENT DEDICATION... I ACKNOWLEDGEMENT... II ABSTRACT...IV TABLE OF CONTENT... V LIST OF FIGURES... VII LIST OF TABLES... VIII ABBREVIATIONS AND ACRONYMS... IX 1. INTRODUCTION Background Aim and Objectives Motorcycle Injury Accident Operational Definitions THEORETICAL FRAMEWORK Human Age and Conspicuity Alcohol and other drug use Inexperience and driver training Licensure and ownership Head injuries Riding speed Risk-taking behavior Lower-extremity injuries Protection devices and injury patterns Vehicle Daytime running lights (DRLs) Headlight modulators Environment General patterns Helmet effectiveness Helmet use laws Conspicuity and daytime headlight laws METHOD Study Setting Research Purpose Study Design Study Population Sample Size and Sampling Calculating Sample size Study Period Measurement Instrument Research Strategy Selection of the study area Data Collection Variables v

9 3.7.1 Dependent variables Explanatory variables Data Analysis Research Quality Internal Validity External Validity Reliability Ethical Considerations RESULTS Socio-demographical characteristics of respondent The safety, awareness and practice The proportion of accidents and injuries The severity of the injuries Association between accidents and motorcyclists background, knowledge and practice Association between injuries and motorcyclists background, knowledge and practice DISCUSSION The knowledge, practice and safety measures The prevalence of motorcycle accident and injury Humans Vehicles Environment STRENGTHS AND LIMITATIONS CONCLUSIONS General Recommendations The Researcher Policy makers, healthcare system providers and health educationalist REFERENCES APPENDIX vi

10 LIST OF FIGURES Figure 1 Figure 2 Figure 3 Figure4 Figure 5 Figure 6 Figure 7 Figure 8 Map of the Tiko Rural Municipality. Source: Tiko Rural Council. The Structure of the sample size. The Students opinion on most important safety measures (n=353). The Students opinion on the causes of motorcyclist accidents (n=353). The students opinion on the most at risk factors (n=353). The main cause of accident and injury (n=124). The distribution of injury among passengers and drivers. The Knowledge and Practice of the students. vii

11 LIST OF TABLES Table 1 Risk factors for motorcycle crash injuries using Haddon s matrix [1]. Table 2 Socio-demographic characteristics of students by sex and P-value for chi2 test of association (n=391). Table 3a Knowledge, training and practice of students by sex and P-value for chi2 test of association (n=353). Table 4 The Proportion of accidents and injuries (n=353). Table 5 The Severity of the injuries (n=124). Table 6 Association between accident and motorcyclists background, knowledge and practice (n=353). Table 7 Association between injury and motorcyclists background, knowledge and practice (n=353). Table 8 Associated with motorcycle accidents and injuries using Haddon s matrix [1]. viii

12 ABBREVIATIONS AND ACRONYMS Abbreviations BAC CI DRL FSLC GBHS IMPAAS ISS OR RTI STARMOTECH USA In Plain text Blood Alcohol Concentration Confidence Interval Daytime running lights First School Leaving Certificate Government Bilingual High School Imperial Academics of Arts and Sciences Injury Severity Score Odds Ratio Road Traffic Injuries Star Modern College of Technology United State of America ix

13 1. INTRODUCTION 1.1 Background Injury from motorcycle is a considerable cause of deaths and disability in the world and is becoming one of the most serious public health problems not only in developed countries but most especially in low and middle-income countries where motorcycle is used purposely for transportation because it is cheap and fast access to areas not pliable by motor vehicles [2]. It is estimated that 5.8 million people died world-wide from motorcycle injuries in 1998, corresponding to a rate of 97.9 per population. Injuries are the leading causes of death in all age groups and for both male and female [2]. Among the first six, 15 leading causes of death in the world for persons aged years, road traffic injuries which are self-inflicted are the leading cause [2]. It is well documented that motorcyclists constitute a high proportion of fatalities in traffic crashes [3]. Motorcycles are a dangerous threat of transportation [4]. Relative to four-wheeled cars, motorcycles are considered as greater risk of death or serious injury to operators and riders [4]. Motorcycling is risky and are 35 times more likely than passenger-car occupants to die in a motor car traffic crash and 8 times more likely to be injured per vehicle mile [5]. In low income countries like for example India, motorcycling has increased rapidly in the last decade with major problem in road traffic injury [6, 7]. The most vulnerable road users are pedestrians and motorbike cyclist in terms of injuries and fatalities as a result of motorbike traffic in India [6, 8, 9]. In India, 452,900 people were injured due to road traffic injuries (RTI) in 2006 and motorcycle accounts for 17.8% [10]. Fatalities due to road traffic injuries are estimated to increase by 150% by the year 2020 [11]. The majority of this increase will be among the motorcycle users [8, 11]. Injuries sustained on motorcycles in high income regions can be understood but the characteristics of crashes and injuries associated by motorcycle users in India are less understood [7]. The annual incidence of non-fatal road traffic injuries (RTI) due to motorcycle user among the age group 5-49 is estimated at 6.3% in Hyderabad [12]. This highlight the enormous burden of road traffic injuries among motorcycle users [12]. In Hyderabad, in the year 2002, motorcycle users accounted for onethird of the fatalities in road traffic crashes [13]. In another low income country especially in Thailand, up to 80% of road traffic injuries patients resulted from motorcyclists [14]. In developed country like Great Britain, the motorcycle riders and passengers had a casualty rate of injury nearly fifteen times that of car occupants in the year 1997 [14]. This accounted for 15% of those killed or seriously injured in 1998 [14]. Motorcycles are the predominant means of transportation in Taiwan [15]. Most 1

14 families own a motorcycle. Taiwan s streets carry as many motorcycles as cars [15]. Most traffic accidents involve motorcycles, and many of their riders are brought to hospital emergency unit with blunt abdominal contusions and some involving hepatic injuries [15]. A large number of motorcycle crashes and fatalities involve riders who lack a proper license or training, are speeding, and/or are not wearing a safety helmet [16]. Motorcycle riders have especially high rates of injury in low income countries. The transfer of effective interventions for motorcycle injuries from high income to low income countries is necessary and highly desirable [17]. However, an understanding of the feasibility of, economic costs of, and potential barriers to implementing these interventions is vital for successful transfer. In low income countries, particularly in Asia, several special motorcyclerelated features are evident [1]. First, motorcycle use has been dramatically growing in low income countries, and it is one of the most important means of transportation because of rapid economic development, convenience in congested traffic, and ease of parking on narrow streets [18]. For instance, motorcycles comprise 95% of registered motor vehicles in Vietnam [19], 67% in Taiwan [20], 63% in China [21], and 60% in Malaysia [22]. Moreover, motorcycle crashes accounted for more than 50% of traffic deaths in Malaysia and Taiwan [22], and 80% of traffic injuries in Thailand [23] and 42% in Singapore [24]. In contrast, motorcycles in the USA comprise about 2% of registered motor vehicles [25], and they are often only ridden for recreation. Second, there are some unique road environments in developing countries, such as congested traffic, intrusive store advertising signs, and a traffic mixture of motor vehicles, and poor roads [26]. Finally, a great proportion of motorcycle riders in developing countries do not use motorcycle safety devices due to inadequate education and no law enforcement [27]. The differences in prevalence of motorcycle riders, the amount of riding exposure, the purpose of riding a motorcycle, the law enforcement, type of motorcycle, and intervention programs should account for large differences in the numbers and incidences of motorcycle crashes and injuries between developing and developed countries, even though more empirical evidence is required. As a result, if these differences are not considered, applying risk factor analytical results and prevention programs from developed countries, particularly to costly road engineering projects, might not be appropriate or feasible for developing countries [28]. Furthermore, road-injury prevention strategies in developed countries protect all vulnerable road users such as motorcycle riders who comprise the majority of road traffic victims in developing countries. Malaysia provided exclusive lanes for motorcycles that reduced motorcycle deaths [29]. Albeit, the experience of successful motorcycle-injury prevention programs, particularly policy interventions such as helmet use laws, legal limits of BAC, enforcement of licensure laws, and speed limits, may directly be undertaken by 2

15 developing countries since these interventions are very important [23, 30, 31] and have a high cost benefit ratio of implementation [32]. In Cameroon, the dwindling economy and the decay of infrastructure have led to the emergence of motorcycles for commercial transportation (popularly called Okada ) over the past one decade. Due to this densely populated region, transportation poses a serious problem. Due to the limited number of taxis, which are mostly private, students, workers and many others are late to their various destinations. The problem was solved with the use of motorcycle the accessible and relatively cheap means of transportation. However, increased use of motorcycle is resulting tomore accidents. This has prompted me to know what could be the causes of injury on motorcycle. School students of age normally use motorcycles themselves or ride with commercial motorcycles to school each day. Secondary school students of this age group can drive motorcycles themselves and according to the ministry of transportation in Cameroon, and they are allowed to own motorcycles. Thus, they may be exposed to very high risk of motorcycle injuries. My observation interested me with the topic: Assessing motorcycle injuries in Tiko Southwest Cameroon: A risk for the secondary school students. 1.2 Aim and Objectives The aim is to study the risk-factors of the motorcycle related injuries among secondary school students in the Tiko municipality, Cameroon. The objectives include: 1. To explore the knowledge, practice, safety measures and causes of motorcycle accident among secondary school students ; and 2. To assess the risk factor and the prevalence of the motorcycle related injuries among secondary school students in the Tiko municipality, Cameroon. 1.3 Motorcycle Motorcycle is a two-wheeled vehicle for transporting one or two riders [33]. Motorcycles are capable of the same speeds as automobiles and are licensed for use on public highways. Most countries require a special driver s license to operate a motorcycle on public roads. Motorcycles are generally bigger, heavier, and faster than mopeds [33]. Motorcycles provide a convenient and relatively inexpensive alternative to automobiles. They are more maneuverable than automobiles and they deliver higher fuel economy. Depending on the size of the engine, a motorcycle may get from 19 to 36 kilometers per liter (45 to 85 miles per gallon), two to four times that of most mid-sized cars [33]. Also, a motorcycle accelerates more quickly than an automobile does. However, riding a motorcycle 3

16 requires special skill. Braking and handling demand extra caution and can be difficult on wet or slick surfaces [33]. Riders use different kinds of motorcycles for different purposes. Motorcycles designed for use on paved streets and roads are called street motorcycles. Street motorcycles are a popular means of transportation during summer months and in warm climates [33]. People often use them for recreational riding as well as for commuting. Off-road motorcycles perform well on dirt or gravel roads or trails. Racing motorcycles are engineered for handling performance and increased speed [33]. 1.4 Injury Injury is a physical damage to the body or a body part and or an instance of physical damage to a body part [34]. Back Injuries cause damage to the bone, cartilage, muscle and ligaments, or nerves of the spinal column [35]. Minor back injuries are common in many sports and other activities; severe trauma to the back can produce paralysis [35]. Head Injury, term used to refer to traumatic head injuries, such as those suffered in falls, accidents, and other blows to the head [36]. Concussion and unconsciousness are often immediate results of traumatic head injury. The long-term effects of head injury can be manifested in a variety of learning, speech, memory, and behavior problems [36]. 1.5 Accident Accident is an unintended and unforeseen event, usually resulting in personal injury or property damage [37]. In law, the term is usually limited to events not involving negligence, that is, the carelessness or misconduct of a party involved, or to a loss caused by lightning, floods, or other natural events (Act of God) [37]. However, the term accident designates an unexpected event, especially if it causes injury or damage without reference to the negligence or fault of an individual [37]. The basic causes of such accidents are, in general, unsafe conditions of machinery, equipment, or surroundings, and the unsafe actions of persons that are caused by ignorance or neglect of safety principles [37]. 1.6 Operational Definitions o Risk: This is when a hazard can result to a disaster [38]. o Injuries: harm or damage that is done or sustained [38]. o Protective wears: refers to protective clothing, helmets, goggles, or other garment designed to protect the wearer's body from injury [39]. 4

17 o Over speed: refers to a situation where an engine is forced to turn beyond its design limit of above 100Km/hr [39]. o Overload: Carrying more than the required number of person on a motorbike (recommended person: ONE). o Speed limit: This is used in most countries to regulate the speed of road vehicles. Speed limits may define by maximum, minimum or no speed limit and are normally indicated using a traffic sign. Speed limits are normally set by the legislative bodies of a country or provincial governments and enforced by national or regional police and/or judicial bodies [40, 41]. 5

18 2. THEORETICAL FRAMEWORK There are many factors associated with the risks of the incidence and/or severity of motorcycle injuries, even though determinants of the injury incidence were rarely differentiated from those of injury severity in motorcycle injuries. Table 1, shows the risk factors for motorcycle crash injuries are classified according to the Haddon matrix [1]. The Haddon matrix is composed of three time phases of an event (pre-event, event, and post-event), along with the three areas influencing each of the crash phases (human, vehicle, and environment). Some risk factors such as age groups (young age or recently reported those aged 40 years in the USA) [42, 43], male gender, a low socioeconomic status [44], nighttime [45], and summer period [46, 47] cannot be directly modified to prevent the occurrence of motorcycle injuries and reduce their severity. Albeit, their effects can often be accounted for by the amount of riding exposure [48] as well as modifiable factors such as helmet wearing, alcohol and other drug use, inexperience and driver training, conspicuity of the motorcycle and rider, licensure and ownership, riding speed, and risk-taking behaviors. These modifiable factors have more relevance for developing and designing prevention programs. Table 1 Risk factors for motorcycle crash injuries using Haddon s matrix Human Vehicle Environment Pre-event Event Post-event Source: see reference[1]. Young age, male, low socioeconomic status, inexperience, crash history, no driving license, traffic violation history, high risk taking behavior, alcohol and other drug use, motorcycle ownership, excessive and slow speeds, and rider s inconspicuity (e.g., without high visibility clothing) Large amount of riding distance and time, excessive speed, no safety devices (e.g., helmet wearing, leg protector, or airbag jacket) Elderly person, pre-existing medical condition Motorcycle inconspicuity (e.g., without daytime headlight use) Motorcycle make Nighttime, poor light condition, summer period, rural area Collision with a heavy object (e.g., moving car) Slow emergency response, poor rehabilitation programs 6

19 There are many other theoretical frameworks in road traffic injuries. To justify why I used the Haddon matrix because it is very simple and clearly give you an understanding of the different risk factors involved. The Haddon matrix is related to my study basically on three main risk factors: Human, Vehicle and Environment. These risk factors were clearly designed in my questionnaire though the environment was not well explicit. The environmental aspect designed in the questionnaire explained just the location of the respondent. The Haddon matrix was designed in a highly economic setting but my study is based on a complete different environment and the added benefit is that it applies to a low middle income country of a population composed of young people that are students in high school. 2.1 Human Age and Conspicuity In a literature review the U.S.A Department of Transportation and the Federal Highway Administration conducted a study, it was found that older adults had a considerably longer search time for all 18 signs than both younger and middle-age adults [49]. In another literature review a study was conducted to examine the relationship between age and sign conspicuity, found that older participants performed markedly worse than younger participants in detecting signs with increased background complexity but not in settings with low background complexity [50]. From a study done, it shows that older adults took longer in the detection of road signs and were also less accurate [51]. The authors suggested that these results can be generalized to real-life scenarios and may explain why older adults have increased difficulty detecting and identifying road signs on a busy street [51]. In addition, most of the research that has been carried out was not etiological in nature but was based on the analysis of existing crash data. One such study examined data on motorcycle crash involvement and the effects of age [52]. In the analysis of this particular study, the authors found age to be a significant confounder of crash involvement with motorcycles. The authors also found that older adults had a higher probability of car-motorcycle crash causation than those in the middle adult group [52]. The authors suggested that this association between age and crash involvement indicates lower motorcycle conspicuity for older motorists, and they proposed that these findings be further investigated, as they have potential to significantly affect motorcycle safety [52]. 7

20 Although there has been minimal research conducted on the relationship between age and motorcycle conspicuity [53]. What has been found within past studies on the conspicuity of road signs and pedestrians linking age to decreased conspicuity performance may be extended to the detection of motorcycles [53]. Nonetheless, all indications are that older adults will have poorer performance when it comes to detecting motorcycles on the roadway [53]. Empirical evaluations of the degree to which age influences one s ability to effectively detect a motorcycle do not exist. The purpose of the research studied here was to explore the association between types of motorcycle headlights, the presence of DRLs on other vehicles, the age of the motorist, and motorcycle conspicuity [53]. Overall, we expect that participants in the young and middle-age groups will outperform those in the older group under all conditions [53]. We also expect that motorcycles with headlights off will be more difficult to detect than those with DRLs or modulator headlights [53]. Furthermore, we look forward to modulator headlights to be more effective than regular DRLs [53]. With regard to following vehicles, we anticipate that motorcycles with lights on will be detected faster if they are followed by a vehicle with its lights off. We also expect that effect to be more pronounced if the motorcycle is equipped with modulators rather than DRLs [53]. Finally, we expect that for the older adult group, there will be more of an advantage with the modulated headlights as opposed to DRLs [53]. Second, the estimated effect of daytime headlight laws is often confounded by regional variations in motorcycle crashes between-state comparisons [54] or factors such as increased in speed limits, helmet use laws, alcohol use, and the minimum legal drinking age within-state comparisons. Finally, increased visibility can be at the expense of other riders who do not use their lights, since car drivers may adopt a strategy of looking for a light rather than a motorcycle per se [55]. Moreover, motorcycle conspicuity may also be affected by the daytime headlight use of other motor vehicles Alcohol and other drug use The consumption alcohol and other drug use are associated most frequently with all kinds of motor vehicle crashes [56-59]; motorcycle drivers are more likely to have consumed alcohol than other motor-vehicle drivers in fatal and non-fatal crashes [25, 60, 61]. For example, 49% of motorcycle crash deaths in USA police reports were attributable to alcohol use, in contrast to 26% of other motor-vehicle crash deaths [57]. When compared multiple-vehicle crashes with single-vehicle crashes, the later account for a greater proportion of motorcycle deaths with a blood alcohol concentration (BAC) greater than 0.1 g/dl, particularly at night [31, 42, 62, 63]. There is risk of being involved in a fatal crash increases with increased BAC levels for all age groups [64] and more than 60% of motorcycle deaths among young riders aged 8

21 15 29 years involved alcohol [65-67]. Nevertheless, in the USA, the peak rate of deaths among motorcycle riders due to alcohol has recently shifted from this group to those aged years [43, 68]. Drinking motorcycle riders involved in a crash are more likely than nondrinking riders to have lost control of their vehicle, and have lower rates of helmet use, more-severe head injuries, and higher ISS levels [47, 69-71]. Non helmeted riders are also more likely to have been legally drunk in a fatal crash [72], and the protective effect of helmets on severe head injuries among drunk riders is reduced [69], probably because alcohol increases susceptibility to hemorrhage shock by eliminating the rider s homeostatic response mechanism [73]. Alcohol use also confounds the measurement of injury severity because the severity levels of head injuries in drunken persons are often overestimated, and a better prognosis for the drunk may be incorrect [74]. There are no existing programs specifically attempted to reduce alcohol consumption by motorcycle riders. Among general interventions such as sobriety checkpoints, legal limits on the BAC, zero tolerance, mandatory jail terms for first convictions, and administrative license revocation, only the enforcement of legal limits on the BAC was effective in reducing alcohol-related motorcycle deaths [57]. The effects of other possible interventions such as a minimal legal drinking age, increased alcohol excise taxes, and responsible beverage service for motorcycle riders have not been examined. As for other drugs rather than alcohol, 32% of motorcycle drivers treated in Maryland trauma centers during had used marijuana (cannabis) prior to the crash, which was significantly higher than the 2.7% of car drivers [75]. Among fatally injured young motorcycle drivers, about one-third had used combinations of alcohol and other drugs such as cannabis, benzodiazepines, or cocaine [76, 77]. In all motorcycle drivers admitted to trauma centers, 24% had used both marijuana and alcohol together with 16% of car drivers [78]. No statistically significant interactive effects among alcohol, marijuana, benzodiazepines, cocaine, or other drugs on injury severity were detected[78, 79] Inexperience and driver training Lack of driving experience is highly associated with a greater risk of motorcycle crashes and injuries [46, 80, 81]. Formal driver training is expected to increase riding skills, experience and decreases the risk of motorcycle crashes and injuries [82]. There are several possible explanations for the lack of benefits of training courses on reducing motorcycle crashes and injuries. First, riding experience per se might not be a determinant of motorcycle crashes and injuries, although it is often associated with age, particularly in young riders [83]. For example in a high income country, a national prospective survey of 4101 riders found that youth played a greater role in motorcycle crashes 9

22 and injuries than inexperience through a pattern of risk taking behaviors, i.e., a willingness to break the law and violate the rules of safe riding [82]. Second, when new safety measures are introduced, riders may adjust their behaviors to maintain the previous level of individual acceptable risk, and the crash rate should not change, if the level of individual risk is not modified; in other words, trained riders may have more confidence for their skills and thus drive with more risk-taking behaviors. Finally, some unmeasured, selective factors for a training group may play a role and weaken the effect of driver training on motorcycle crashes and injuries [84] Licensure and ownership Riding a motorcycle without a valid license is associated with higher risks of crashing and serious motorcycle injury in high income countries and many other developing countries as well [9, 85]. Among fatally injured motorcycle operators, only 75% had a valid license [25], and the lowest licensure rate often occurs in younger drivers aged 20 years [9]. When compared licensed riders with unlicensed riders were less likely to report using the low-beam headlight in daytime, wearing body protection, or driving without drinking alcohol [70, 86]. Motorcycle drivers who crashed and who did not own the motorcycle were more likely to be unlicensed than those owning the motorcycle, and owners involved in a crash were less likely to have a license than those not in a crash [87]. For instance, in a high income country particularly in New Zealand where the minimal legal driving age is 15 years, only 36% of 18-year-old drivers had a valid license and 72% did not own the motorcycle they were driving. Not having a license, not ownership of a motorcycle and being a youth can be associated to motorcycle crash injury [88]. Study shows that drivers who borrowed a motorcycle were more likely to have a crash at night, while attempting to execute a turn, riding at slower speeds, or committing a traffic violation compared with those who owned the motorcycle [89]. A proof of a valid license is a prerequisite for purchasing a motorcycle, stringent enforcement of licensure laws and severe penalties for lack of a license, to obtain a motorcycle license [87, 88]. Study shows that in some high income countries especially in the US and New Zealand have a graduated driver licensing systems were effective in reducing motorcycle injuries and deaths [90, 91], particularly for riders aged years [92]. The effect of the graduated driver licensing system may result from a reduction in exposure to motorcycle riding [92] and or from appropriate education [90]. 10

23 2.1.5 Head injuries Head injury is a leading cause of death in motorcycle crashes [93, 94], particularly in single motorcycle crashes and head-on collisions [95]. For example, in the US, 53% of motorcycle deaths from 1979 to 1986 were a result of head injuries, and 69% of head injury deaths among motorcycle riders were white males aged years [96]. In every motorcycle riders admitted to the hospital, the most common head injury is concussions, followed by brain contusions or hemorrhage, facial fractures, and skull fractures [97-99]. Brain injuries are frequently caused by deceleration forces, particularly with rotational kinetics [100]. It should be noted that head injuries are still the leading cause of death in helmeted riders [101, 102] Riding speed Riding with higher speeds at the time of impact are associated with more serious motorcycle injuries [103]. In high income countries especially in the US speeding by motorcyclists in fatal crashes is about twice the rate for drivers of automobiles or light trucks [25]. In a study from some literatures review, speed is also responsible for almost two-thirds of motorcycle deaths among single-vehicle crashes [104]. A study shows that when crash speeds exceeded more than 50 km/h, there was a reduction in helmet effectiveness in preventing motorcycle deaths [105]. At high speeds, the fixed and non-fixed parts of the body such as the skull and brain move differentially, and brain injuries due to deceleration may occur [106]. In a motorcycle injury due to high-speed crash, a helmet can be lost if the chin strap is not securely fastened [100]. Regulating speed limits is a means of reducing traffic speed. It was estimated that persons driving on highways with a speed limit greater than or equal to 55mph were 3.7- times more likely to be killed in crashes than those driving at lower speed limits for all types of vehicles [107]. In a study, speed camera networks was found to decrease all type of injurious crashes, including those occurring in daytime and nighttime, on roads with speed limits of 30 and 60 70mph, and for crashes that injured motorcycle riders (by 63%) and other road users by 17 78% [108] Risk-taking behavior The risks of motorcycle injury and death are highest for the young [42, 46, 97, 109] in the US [43]. Findings from a study carried stipulate that the overrepresentation of young riders in motorcycle injuries was due to inexperience in operating a motorcycle or a higher exposure to riding [110]. Another finding from some studies shows that the risk-taking characteristics of 11

24 young riders contribute to the high risk of motorcycle injuries, and risk-taking behaviors among motorcycle drivers may include speeding, drinking while riding, not using a helmet while riding, unlicensed riding, running yellow lights, and driving with too little headway [46, 82], and these behaviors are associated with each other [111, 112]. A study shows that motorcycle drivers involves in crash injuries due to risk was associated with experience, gender, distance ridden, and geographic region [113]. The risk perception of adolescent drivers corresponded to the actual risk of motorcycle crashes [17], but they do not modified their risk-taking behaviors or reduced risk-taking levels, even after experiencing an injury [114]. On the other hand, risk-taking behaviors among very young persons may be represented by stress and aggression, an expression of independence, or a means of increasing arousal or impressing other people [115]. As a result, health-promotion education only using negative consequences of motorcycle and other motor-vehicle crashes intended to reduce high risk-taking behaviors among young person s might not readily succeed, even if these educational materials do increase risk perception [116] Lower-extremity injuries Lower-extremity injuries are most common in non-fatal motorcycle crashes, affecting about 30 70% of injured riders [95, 109, ]. In lower-extremity injuries, fractures are most common and have several outcomes [119], in terms of permanent disability, economic costs, and the return to work [121, 122]. Of these fractures, the tibia is the most common site, followed by the femur, foot, and patella [119]. Femoral fractures are the most common long bone injury in motorcycle deaths [93] Protection devices and injury patterns Helmets reduce the incidence and severity of head injuries in motorcycle riders. Non helmeted riders are at greater risk for severe head injuries of all types [98, 117, 123, 124], as well as facial injuries and high-severity facial fractures [125, 126]. No differences between helmeted and non-helmeted riders were detected in those with cervical and thoracic fractures and spinal cord injuries [123, 125, ]. Protective clothes seem to reduce the risk of soft tissue injury among motorcycle riders, no advantages in the occurrence of fractures were found [131]. Heavy boots and work shoes are effective in protecting against ankle and foot injuries [132], and crash bars on motorcycles protect riders lower legs when the impact is from the side [120]. 12

25 2.2 Vehicle Daytime running lights (DRLs). In a literature review, the first study to formally examine the effectiveness of DRLs was conducted to evaluate crashes for a bus company [133]. The result shows that the compulsory use of DRLs decreased the crash rate per million miles in daylight conditions by 40% compared with the year prior to implementation [133]. When transferred to motorcycle use, similar results have been found [133]. In a historical study attempting to determine the effectiveness of regulations mandating the use of DRLs on motorcycles in Indiana, Montana, Oregon, and Wisconsin cities, has crash evaluations before and after implementation of the law to determine efficacy [134]. The evaluation is known as the Franklin Institute Report, it has been used as a basis for justifying the mandate of DRLs for manufacturers as well as for the 21 other states that currently regulate DRL use [134]. The author and colleagues concluded that the use of high and low beam headlights increased the conspicuity of motorcycles, as was evident in their decreased crash involvement [134]. In a laboratory experiments conducted using conditions of both day and night, it was found out that overall conspicuity increased the conditions in which motorcycles were fitted with high and low beams compared with conditions in which motorcycles had no lights [135]. In a comprehensive review of a literature, it was concluded that several studies provide evidence supporting the use of motorcycles DRLs during daytime hours, as motorcycles with DRLs were less likely to be involved in crashes than those without them [136]. Although some researchers think that the efficacy of DRLs on motorcycles is losing ground because of the prevalence of DRLs on other vehicles [ ], most agree that the compulsory use of DRLs on motorcycles significantly reduces crash involvement and thus increases overall conspicuity [136, 137, ] Headlight modulators A disproportionate number of motorcycle crashes occur when other motorists fail to detect a motorcycle approaching from a degree off center in the periphery [145]. The finding suggested that certain emphasis should be placed on aspects of conspicuity that recognize this constraint [145]. The human visual system has specialized features that make the periphery of the visual area receptive to the detection of motion [146]. As such, it may be possible to increase the conspicuity of a motorcycle through the use of flashing lights in the form of headlight modulators [146]. 13

26 From a literature review to determine the effectiveness of headlight modulators, the detection times of participants in real-world driving situations was tested [141]. The results showed that during both daytime and nighttime conditions, both low-beam and high-beam headlights as well as modulating headlights significantly improved the conspicuity of a motorcycle [141]. Although the aforementioned research indicates a relationship between DRLs, modulators, and motorcycle conspicuity, most of the studies reported were non experimental in nature and were also conducted more than 20 years ago [53]. Etiological research into the effects of headlights on motorcycle conspicuity is severely lacking, especially as it relates to the impact of current compulsory motorcycle headlights-on laws and the prevalence of other vehicles on the road with voluntary DRLs [53]. 2.3 Environment General patterns A motorcycle rider often sustains multiple injuries in a crash [117, 147]. Head injury is the most common in fatal motorcycle crashes and it contributes to about one-half of all motorcycle deaths [94]. Chest and abdominal injuries (e.g., lung contusion and liver laceration) are the second most common cause of fatal motorcycle crashes comprising from 7% to 25% of motorcycle deaths [93, 102, 124, 148, 149]. Cervical spinal injuries are more likely to occur in fatal crashes other than those to spinal regions [93]. The lower extremity is the most common site of an injury in most motorcycle crashes [97, 117, 119, ]. The thoracic spine is the most commonly injured spinal region in motorcycle crashes [93, 153, 154], while riders with severe injury to the trunk are likely to have severe injuries in the same or other anatomic regions [155]. Facial injuries are diagnosed in one-fourth of all injured riders, and they are associated with a risk of traumatic brain injuries [99] Helmet effectiveness Helmet is a rigid fiberglass or plastic shell, a foam liner, and a chinstrap, is the principal equipment for preventing or reducing head injuries from motorcycle crashes. Based on police reports, helmets reduced the risk of motorcycle deaths by 29% during [156, 157], and their effectiveness increased to 37% during possibly due to improvements in helmet design and materials [158]. After adjusting for age and crash characteristics, nonhelmeted riders were 2.4-times more likely than those wearing a helmet to sustain brain injuries or skull fractures [159]. After adjusting for collision type, posted speed limits, and environmental factors, non-helmeted riders had a 3.1-fold increased risk of head injuries or 14

27 death compared with helmeted riders [160]. Moreover, after stratification by crash severity measured by the Injury Severity Score (ISS) for other than head injuries or repair costs of motorcycle damage, the protective effect of helmets on head injuries remained statistically significant [161, 162]. The results consistently indicate that non helmeted riders are more likely to have head injuries, die, require longer hospitalization, and have higher medical costs compared to helmeted riders. Three types of helmets (full-face, full-coverage, and half coverage) are effective in reducing head injuries [132, 163], but the differences in effectiveness among these types of helmet have not been well examined. In addition, detachment of helmets during motorcycle crashes is not uncommon [100, 164], and head injuries seem to occur more frequently and are more severe for riders who wear a nonstandard helmet than those who wear a standard helmet [165]. There are possible side effects from helmet use. First, there has been assumption as to whether the use of helmet increases the risk of cervical spinal (cord) injuries in a crash, because injuries to the neck and base of the skull are occasionally found in helmeted riders [ ]. However, those findings were from studies with small sample sizes, lack of comparison group(s), or small numbers of fatal injuries, or they failed to adjust for confounders such as age and alcohol consumption [171]. On the other hand, many more studies have found no evidence for such an association [117, 123, 125, 127, 129, 130, 151, ]. Second, the influence of a helmet on the rider s vision and hearing has been raised. Although helmet shave a small effect on the lateral vision of motorcycle riders, studies have shown that riders compensate for this restriction by increasing head rotation when making turns, and thus hearing and visual acuity are not overly restricted by helmet use [176]. In a prospective cohort study, no increased risk of motorcycle crashes occurring to helmeted riders was found, even after adjusting for riding distance, riding time, risk-taking level, and many other human, vehicle, and environmental factors [46] Helmet use laws The reductions in head injuries, the likelihood of death and medical costs due to helmet use provide the basis for compulsory helmet use laws [177]. Increasing helmet usage among all motorcycle riders (comprehensive helmet laws) or only young riders (partial helmet laws), helmet use laws is implemented to reduce or prevent head injuries and deaths. In Italy and Spain for example, enactment of laws increased motorcycle helmet use from 20% to more than 95% [178, 179]. 15

28 However, implementation of policies based only on these scientific data has been difficult [180, 181]. Policy waves in state legislative activity of helmet use laws have been encouraged by federal legislation in the US. In 1991, the US Congress created economic incentives for states to enact helmet use laws, but by 1995 had reversed its position and lifted federal sanctions against states without such laws, which paved the way for state governments to repeal the laws [182]. In general, comprehensive helmet laws are significantly associated with an increase in helmet usage followed by decrease in the total number of motorcycle deaths, head injuries, days of hospitalization, and medical costs. Helmet laws also had the least cost per year of lives saved among all major traffic safety programs [183] and their cost benefit ratios range from 2.3 to 5.07 [32] Conspicuity and daytime headlight laws In car and motorcycle collisions, two-thirds of car drivers claimed not to have seen the motorcycle or to have seen it too late to have avoided the collision [85]. In the number of ways to improve the conspicuity of motorcycles or their riders, the use of high or low-beam headlights during daytime hours was better than other devices designed to raise conspicuousness such as wind fairing and reflective fluorescent jackets [141]. In a developed country like New Zealand, high-visibility clothing and white-colored helmets were found to reduce the risk of having a crash compared to other measures [144]. The use of headlight during the Daytime has been advocated to increase motorcyclists safety; however, laws governing this have not consistently been found to reduce motorcycle crash injuries [22, 54, 144, ]. There are several reasons for these inconsistent findings in the study. First, conflicting assumptions were used across those studies to evaluate the impacts of daytime headlight use on motorcycle crash injuries. If the potential benefit of motorcycle daytime headlight use is assumed to prevent motorcycles and riders from being hit by other motor vehicles (i.e., avoiding multiple-vehicle crashes), those including all single and multiple-vehicle crashes in the preventive outcome may have underestimated the effectiveness of daytime headlight use [22, 187]. 16

29 3. METHOD 3.1 Study Setting The study was based in Tiko Municipality-Cameroon located in the southwest region. Cameroon has an extremely heterogeneous population, consisting of approximately 250 ethnic groups [188]. In this Southwest region, where Tiko Sub Division is located is estimated to have a population of about [189]. Tiko, Cameroon is located at (latitude in decimal degrees), (longitude in decimal degrees) at an elevation/altitude of meters. The average elevation of Tiko, Cameroon is 65 meters [189]. This town is at the coastal region and has tourist sites with many tourists visiting these areas. The town is composed of industries, schools, business agencies etc. The town is densely populated and host many other neighboring towns like Mutengene, Likomba, and Missellele etc. [190]. The study setting is represented on a map below in Figure 1 where all the schools are situated in the Tiko Municipality. Figure 1: Map of the Tiko Rural Municipality. Source: Tiko Rural Council 17

30 3.2 Research Purpose Basically, the most three important research purposes include describing, exploring or explaining the phenomenon of interest [191, 192]. This study was mostly explorative. To explore the practices and the attitudes towards motorcycle usage among secondary school students and to assess the risk factor and the prevalence of the motorcycle related injuries among secondary school children in the Tiko municipality, Cameroon. Also, further explorative research was done to understand improvements on ways to address this public health problem Study Design A cross sectional study was conducted based on secondary school students from years of age in the public and private schools that were exposed to the risk of injuries in the Tiko municipality. A descriptive study is concerned with the conditions that exist, such as determining the nature of prevailing conditions, knowledge practices and attitudes, opinions that are held, processes that are going on, or trends that are developed. They also dispute that descriptive studies can be generalized beyond the given sample and situation [193]. The reason for choosing this study design was in consideration of the purpose of the study, research question and the target population. It is the most suitable design that will help the researcher design and collect data from the respondents. Descriptive study can be described as a kind of study design that determines and report the way things are happening at a point in time [194]. There are some advantages in this research design. This includes getting information from a wide range of people by asking the same set of questions to a group of individuals through mails, telephone and by hand on the basis of data collected at a point in time [195]. It is very crucial when the researcher attempts to describe some aspects of a population by selecting unbiased samples of individuals who are asked to complete questionnaire, interview and test [195]. Beside these advantages, there are some weaknesses in descriptive study. It was contended that errors and lack of a study research in education at some points appear the way problems are initially chosen and defined through the selection of population and sample to items construction and analysis of resulting data [196]. Furthermore, having enough copies of the questionnaire completed and returned so that meaningful analysis can be made is another weakness of descriptive study design [197]. Despite these weaknesses, the descriptive study design is most appropriate for providing answers to many research questions and ensuring one to achieve the purpose of the study. 18

31 3.2.2 Study Population Most of the schools in this area are privately owned and some are public owned institutions. The target populations of the study were mostly on high school students within a certain age group There were six high schools in this region and based on its accessibility, a total of 400 students were selected by random selection. I chose four of these schools since two of the school s students are boarding where they leave within the campus. These two schools were not chosen because the students rarely use motorcycle except when they are on holidays. In each class, students were asked to stand on condition that they are 16 years and above. The class register was used to select the student randomly Sample Size and Sampling To calculate the sample size, I have used the prevalence of motorcycle injuries in another country in Nakuru, Kenya [198]. The study aimed at determining the pattern of injuries sustained by motorcyclists hospitalized at the Rift Valley Provincial General Hospital, a major public hospital in Nakuru, Kenya [198]. A cross sectional study spanning from July 1st 2008 to 30th June 2009 was conducted. According to the article, the prevalence of motorcycle-related injuries in Kenya was 1% in year 2009 [198]. Medical records of the patients were used to identify data on patient demographics, nature of injury (body region and severity) and outcomes [198] Calculating Sample size Z 2 pq n = e x (1-0.01) = x 0.9 = = = 146 The number of schools required to fill these questions were basically four high schools both private and public in the Tiko municipality. The reason was that there are many schools in this area but those schools which frequently used motorcycle to schools are mostly public and lay private. There were about eleven secondary schools in total in Tiko, Likomba and 19

32 Mutengene but only six of them include high schools. The average youngest student in high schools was about 16 years old. Since the sample for this study comprises students aged 16-24, the study was conducted only in the high schools of Tiko municipality. The numbers of girls were slightly equal to the numbers of boys which helped me to know if there were any differences between these two groups. Since the total sample size was 146 students, I will interview fifty students from each of the three high schools. The students were randomly selected from their class register. For example every first, third student in the class register were chosen. To minimize selection errors from my calculated sample size, I increased the sample size to 400 because of the vast populations in all the high schools and also to have an estimated proportion of accidents and injuries. The age group range was limited to those students who are years old and therefore can use motorcycle themselves for transportation or pay the motorcycles riders. This study helped me know how the distribution of risk to injuries was quantified. This method analyzed the prevalence rate across the age group and those who were exposed to injuries and the risk factor was known. 3.3 Study Period The field study for data collection was conducted from December, 2011 until the end of January, Measurement Instrument The main instrument used for the data collection was mostly a designed close-ended and some open-ended questionnaire. It was taken from a sample questionnaire used in a similar study in London to measure the attitude of motorcycle riders [199]. The instrument was chosen because of its simplicity, ability to save time, and the possibility to make comparison as well as gather data from a group of people at ago. The questionnaire was modified and designed to fit the Haddon matrix. The questionnaire was divided into three major sections composed of 30 questions. The first part covers the respondents demographic information such as age, sex, educational level and area of residence. The second part basically describes the knowledge, safety and practice regarding motorcycle. The last section however gives an estimate of the prevalence rate of accidents and injuries among the students. Before they could answer the questions, a pilot study was done from another school to test the validity of the questionnaire. The pilot study was conducted in a local boarding school among six students in total, i.e., two students (a boy and a girl) from each of the following age groups: 16-18, 19-21, years old. This was to test the validity of the questionnaire. After the pilot study, all unclear question(s) was taken into consideration and changes were made where 20

33 necessary. The updated questionnaire was used for the data collection. Questions which the students could not understand were explained and restructured. 3.5 Research Strategy The research study was carried out based on primary data. The primary data were obtained from the questionnaire collected among high school students and some information came from an extensive review of literature such as published articles, textbooks, documents from the Tiko Municipality and the regional delegation of transportation in Cameroon Selection of the study area Tiko is a small town in the Southwest region - Cameroon with a fast growing population which was estimated to be about [189]. This town comprises of many government offices, schools, businesses, companies and some touristic area like beaches. Due to this fast growing rate in population, students and workers depends on cheap and fast means of transportation. The number of schools in this area was increasing as well and the students deem it very necessary and convenient to use motorcycle to school. Since the introduction of motorcycle usage for commercial purpose, most people divert their interest using motorcycle. The rate of motorcycle injuries became alarming and nothing has been done to sensitize the population about this major public health problem. Since, I am currently studying public health; my interest was ascertained to this particular problem. Another reason is that, the knowledge, altitude and practice of the motorcycle riders and some of the students to respect the rules and regulations was a major issue as well. No implementation of the laws enforcement by the government to correct this major problem. I really want the government to be aware of this problem so that something can be done in the nearest future. I selected this area because I intend to know the gravity of injuries among the students who are using motorcycle as means of transportation. 3.6 Data Collection Primary data was used as a medium for data collection. Only students aged from were given the questionnaire to answer. The students were all in high schools. A time for the research was made available by the director of the schools and the teacher having the class hour was notified to allow this period for the researcher to administer the questionnaire. The researcher asked the respondents if they belonged to the age ranged years and should stand. Majority of them were 16 years and above. I gave two pieces of paper to a student to pick, on which it was written one and two. The student picked one of the papers on which it 21

34 was written one. I gave the questionnaire to those whose number in the class register were odd and no questionnaire was given to those who had even number on the class register. After this process, the researcher explained to the students the purpose of research study. They were told about their right to decline from the study if they deem it necessary and the need for them to answer the questions individually. The researcher promised them of confidentiality and vowed not to release the data for any other purpose apart from the purpose it was meant for. After the explanation, the questionnaires were personally administered to the respondents with the help of some staff of the various schools who showed a degree of interest in the research. During the answering of the questionnaire from the respondents, the researcher explained each question to the respondents for clarification. Where the respondent indicated on a question which required him or her to end the interview, the researcher demanded for the questionnaire. This was done all through the whole session in all the schools. They were given 15 minutes to respond to the questions, after which the questionnaires were collected back from them. This was done in my presence. These questionnaires were given to the students in all the four high schools. The answered questionnaire was input into Epidata entry for analysis. A quantitative study was carried out for this research project. The most essential material used was questionnaires. No interviews or observation was carried out. The questionnaires were distributed in class for the school children to fill in my presence and I gave explanation on the question(s) which are misunderstood. The questionnaire was in English. 3.7 Variables Dependent variables Accidents Accident was derived from the question: Have you ever been in an accident when driving a motorcycle? This variable was measured based on YES or NO. All the respondents who answered YES in this study were reported of having an accident. Those who said NO were not considered of having an accident. No was taken as the baseline. I coded YES as 1 and NO as 0. I also tried to find out how many times they have had an accident. I measured this as 0 for one and two times of accidents, 1 for three and four times of accidents and finally 2 for five times or more. 22

35 Injury The students were asked if they have ever sustained injury. This variable was measured based on YES or NO. I also tried to find out from the students how severe the injury was. If they indicated YES they had an injury. The severity of the injury sustained was subjective and I coded it as YES or NO. No was taken as the reference Explanatory variables Gender This was categorized into two groups: Male and Female. One was for male and two was female. One was taken as the reference. Age Age was denoted as age group and was categorized into three categories: 16 to 18; 19 to 21; and 22 to 24. The age group 16 to 18 was taken as zero which was referred to as the baseline, the age group 19 to 21 was taken as one and the age group 22 to 24 was taken as two. Educational certificate This was structured based on the educational standard of certificate in Cameroon. The basic educational level is known as FSLC; follow by Ordinary level and then Advanced Level. The highest education was Advanced level and was denoted zero which was the reference, Ordinary level was taken as one and the least education was taken as the risk factor and referred to as two. Area of resident Here I classified the area where the student lived. These areas are all within the Tiko Municipality. The areas where categorized into four: Tiko, Likomba, Tiko-Douala road and Mutengene. Tiko was referred to as the baseline. Likomba was one, Tiko-Douala road as two and Mutengene as three. License The students were asked to indicate if they have a driving license or not. I denoted it by YES or No. Yes was the baseline. 23

36 How many years of motorbike license? I categorized this into three categories: 1 to 2; 3 to 4; and over 5 years of experience. Those who have over 5 years are taken as the baseline. Usage of motorcycle Here I categorized this variable into three categories: Always; often; seldom and never. Those who never used motorcycle were taken as the baseline and their interview ended. Those who indicated Always were taken as a risk factor. Motorcycle training I classified this variable into three categories: Formal training, informal training and no training at all. The baseline was formal training while the risk factor was no training at all. Wear helmet This was classified into five categories: Always, Frequently (over 50% of the time), occasionally (less than 50% of the time), Never and Do not know. I stratified them into three categories: Always, occasionally and never. This was to increase the sample size power. The baseline was always while the risk factor is never. Wear bright and reflective clothing This was classified into five categories: Always, Frequently (over 50% of the time), occasionally (less than 50% of the time), Never and Do not know. I stratified them into three categories: Always, occasionally and never. This was to increase the sample size power. The baseline was always while the risk factor is never. All the other variables like use daytime headlights, wear a protective jacket, wear protective trousers, ride above speed limit, pass two or more vehicles at the same time and misjudge the speed needed to negotiate a bend in the road were classified into three categories as well. Ride while feeling tired This was classified into five categories: Always, Frequently (over 50% of the time), occasionally (less than 50% of the time), Never and Do not know. I stratified them into three categories: Always, occasionally and never. This was to increase the sample size power. 24

37 The reference was taken as never and always as risk factor. The reason is because those who ride while feeling tired are highly exposed to accident and injury and cannot be taken as reference Ride while under the influence of alcohol and drugs This independent variable was stratified into five categories: Always, Frequently (over 50% of the time), occasionally (less than 50% of the time), Never and Do not know. I stratified them into three categories: Always, occasionally and never. This was to increase the sample size power. The reference was taken as never and always as risk factor. This reason is that those who ride under the influence of alcohol will be highly exposed to accident and injury and cannot be referred to as the baseline. Number of student on the motorcycle This independent variable was categorized: One, Two and greater two. Those who were on the motorcycle single was categorized a zero and was denoted as the reference group, while those who were two on the motorcycle was categorized as one and final those who were more than two upwards were categorized as two. Collisions while overtaking other road users This variable was the most at risk of motorcyclists. The variable was measured in two categorize: Yes and No. No was for those who think the variable is not at risk while Yes signifies risk of motorcyclists. These variables: Being hit from behind by other road users (rear-end shunt), collisions with right-turning vehicles, collisions with left-turning vehicles, poor riding technique leading to loss of control of the motorcycle and over-shooting bends in the road were also measured the same as well. Severity of the injury This variable was measured by Yes or No. Yes was denoted by severe and No was not denoted not severe. The same applies for the following: go to the hospital because of the injury and stay in the hospital for one night or more because of the injury variables were also measured as Yes or No. 25

38 Do you drive motorcycle? This variable do you drive was measured by Yes or No. Yes was taken as the reference and risk factor and No was taken as the protective factor. 3.8 Data Analysis The frequency and the prevalence of risk-factors for the motorcycle-related injuries were calculated. The prevalence of the motorcycle-related accidents and injuries in the studied population were also calculated. The logistic regressions were used to calculate the association between the risk-factors and the motorcycle-related accidents and injuries in the sample. The software package in analyzing this data was STATA version 11. The Epidata entry version 3 was used to input all the data into the computer before being analyzed using STATA version 11 software. This software is useful because, all the variables were defined in an organized manner. After inputting the data, the software was able to transfer all the information into STATA version 11 for analysis [200]. The non-response rate and reasons for non-response were analyzed. 3.9 Research Quality Two tests have been used to assess the quality of this thesis: validity and reliability of the study [201]. Reliability can be defined as the extent to which an observations or measures are consistent if done many times while validity is the extent to which an observation or measures are accurate if done many times [201]. Validity can be described as internal or external [201]. The internal validity is the most important, which are the extent of a results to a study that reflect the true situation in the study sample in the absence of any alternative explanations [201]. These alternative explanations could be chance, bias and confounders. The other issue is the generalizability or external validity. This explained if the results of a study are applicable to populations other than the study population [201] Internal Validity Internal validity is the degree to which the study findings can represent a true reflection of the population [202]. Does this result reflect what actually exist in the population? This is what was studied and measured and the researcher believes it has been measured? [202]. Remenyi et al. state that validity means that a measurement instrument s ability to measure what it should measure [203]. Have the author discussed the limitations of this study? What conclusions do they draw with respect to the study? Are the conclusions justified? Does the study appear to be internally valid or could the results be done due to chance, bias or 26

39 confounding? [201]. In public health we are dealing with real people and complex exposures that are often difficult to measure and/or impossible to control adequately and we are, quite rightly, constrained as to what we can do by codes of ethics [201]. Also, the evidence reported in this research paper might not always be strong but, if it is the best that is likely to be available, we should not discount it because of the flaws. Rather we should draw from it what information we can from the data collected [201]. Data collections were based on questionnaires which were used as means to measure the accuracy. The data were input into Epidata entry version 3. The numbered questions were categorized as variables. The response from each variable was denoted as binary for some of the questions while some answers were multivariable. The data were manually input for all the respondent and unanswered questionnaire was not taken into consideration. These study findings reflect a true situation on ground as per what is happening in the area regarding motorcycle usage for transportation among secondary school students. The data were cleaned during entering and after entering to increase the validity and data quality External Validity External validity is the degree to which the study findings can be generalized beyond the study targeted population [202]. If a study is not internally valid, then the results should not be applied to anyone [201]. There are no firm rules to help with generalizing from a study to the wider population [201]. These study findings can be used to generalize what is happening in the other motorbike settings used for commercial purpose in the different regions in Cameroon. External validity is defined by [192] as establishing the domain to which a study s findings can be generalized. It was stated that if results are generalized then they must have an internal validity [204] there is no point in discussing the generalization of meaningless results [204]. In order to increase the ability to generalize one need to use multiple case studies with a crosscase analysis process [202] Reliability Reliability is the ability of a research or study findings to produce similar results when uses to measure phenomenon repeatedly under the same measurement conditions [201]. The effect of a study found consistently across different types and/ or in different populations gives some reassurance that the results are true [201]. However, lack consistency does not in itself rule out casualty [201]. Differing results could reflect variation in a study or quality, or an exposure could have a different effect in people with a different genetic make-up [201]. 27

40 3.10 Ethical Considerations The participation in the study was voluntary and anonymous. All potential participants were informed about the study s aim and objectives. They were also informed about their rights and a possibility to withdraw from the study at any time. Prior to the study I obtained permission from the following: o o o o o Approval or permission from the school directors. Approval was obtained from each teacher in class where the questionnaire was distributed to the students. No identifying information of the students was collected in the questionnaire. Verbal informed consent from all students involved in the study. Each answered questionnaire was uniquely coded and numbered in all the schools. 28

41 4. RESULTS The sample size structures on how the respondents answered the questionnaire are presented in figure 2. The total response rate was 391(97.75%) out of 400 (100%) was recorded. A total of 9 (2.25%) non-response rates were also recorded from all the four schools were the data was collected. In further analysis, 38 of the respondents never used motorcycle and were all excluded. A total of 353 were included in the analysis and 206 of the respondents had an accident while 147 never had an accident and were excluded from the descriptive analysis but included in the logistic regression. Finally a total of 124 had an injury as a result of accident (figure 2). 400 Sample size 391 Responded 9 Non-response These were respondents who used motorcycle. 353 Study Sample 38 Excluded These were respondents who never used motorcycle. 206 Accidents 147 No Accidents These were respondents who never had motorcycle accident. 124 Injuries 82 No Injuries Figure 2: The Sample Size Structure 29

42 4.1 Socio-demographical characteristics of respondent Table 2 illustrates the socio-demographical characteristics of the respondents. The age group distributions were similar between boys and girls, with the majority of them being among the age group years old. The majority of respondents had ordinary level education. However, girls in general had slightly higher level of education. This was statistically significant. There were very few respondents who lived in the Tiko-Douala road as compared to the other students in the different area of residences. However, most of the students lived in Tiko. All four schools were equally represented in the sample, although there were more boys in STARMOTECH and the opposite was true for the Sure Foundation. This was also statistically significant. The majority of the respondents used motorcycles (90.3%). There was no statistical significant difference in the motorcycle usage between boys and girls. Table 2 Socio-demographic characteristics of students by sex and P-value for chi2 test of association (n=391) Variables Total (N=391) Sex P-Value Male (n=202) Female (n=189) Number (%) Number (%) Number (%) Age groups (Years): Education: Advanced Level Ordinary Level First School Leaving Certificate Residence: Tiko Likomba Tiko-Douala Road Mutengene School: GBHS IMPAAS Starmotech Sure Foundation How often do use motorcycle? Never Seldom Often Always

43 4.2 The safety, awareness and practice A total of 38 (9.7%) who never used motorcycle were excluded from the further analysis. Thus all further analysis was based on a sample of 353 students. To study student s safety, awareness and practice, students were asked a number of questions. First, as shown in Figure 3, the majority of the students considered not driving under the influence of alcohol, observing the speed limit and wearing protective clothing and helmet were the most important safety measures. Lastly, most of the students acknowledged that the least important safety measure was making you self-visible to other road users. The majority of respondents (69%) believed that motorcyclists themselves were the main cause of accidents due to the lack of knowledge or poor riding skills. This result is shown in figure 4. Wearing protective clothing/helmet 14% Appropriate number of passengers 9% Most Important Safety Measures Maintenace of motorcycle 7% visibility to road user 4% Not driving while tired 6% Positioning of motorcycle to road conditions 5% Reading road signs 13% Observing speed limit 19% Not driving under influence of alcohol or drugs 23% Figure 3: The Students opinion on most important safety measures (n=353) 31

44 Frequency (%) Causes of motorcyclist accidents 0% 17% Don't Know 11% Car drivers Pedestrians 3% Motorcyclists themselves 69% Others Figure 4: The Students opinion on the causes of motorcyclist accidents (n=353) Furthermore, the respondents selected the two most at risk factors which motorcyclist were exposed of. Most of the respondents 267 (75.6%) thought poor riding technique leading to loss of control of the motorcycle and 254 (72.0%) thought collisions while overtaking other road users were the most risky. The respondents 20 (5.7%) also thought that motorcyclist were least exposed to risk when it comes to collisions with left-turning vehicles. 80,0 Motorcyclist most at risk 70,0 60,0 72,0 75,6 50,0 40,0 30,0 31,2 20,0 24,7 10,0 0,0 11,9 Collision due torear-end shunt Collision rightturning overtaking vehicles 5,7 Collision leftturning vehicles Poor driving techniques Over-shooting bends Figure 5: The students opinion on the most at risk factors (n=353) 32

45 In Table 3, the majority of the respondents who were males rode motorcycle, only few owned motorcycle and more boys owned motorcycle than girls. This was statistically significant. Among all the respondents who drove motorbike, findings shows that over 50% of the boys have undergone formal training as opposed to the girls that are not likely to be involved in any formal training. The missing values in table 3a were respondents who did not have ownership of a motorcycle so they were not liable to answer this question. I referred to them as non-response. A great majority of the respondents were passengers 77.1% and 39.1% of the boys drove motorcycle as opposed to 94.7% of the girls who did not drive motorcycle (Table 3). As showed in Table 3 the results revealed that majority did not wear helmet, bright or reflective clothing, did not use daytime headlight, wear protective jacket or protective trousers especially among girls. This was statistically significant. However, majority of the respondents never drove above speed limit as opposed to those who always drove above speed limit. This was non-significant as well. Also, most of the respondents reported they never rode motorcycle while feeling tired or rode while under the influence of alcohol. This was non-significant. The number of students that were drivers went further to answer questions that were meant for the passengers. 33

46 Table 3 Knowledge, training, and practice of students by sex and P-value for chi2 test of association (n=353) Variables Total (N=353) Sex P-value Ownership: Male (n=184) Female (n=169) Number (%) Number (%) Number (%) No Yes Training: Formal training Informal training No training at all Missing values Do you drive motorcycle? Yes No When on motorcycle how do you: Wear helmet? Always Occasionally Never Wear bright/reflective clothing? Always Occasionally Never Use daytime headlights? Always Occasionally Never Wear protective jacket? Always Occasionally Never Wear protective trousers? Always Occasionally Never Ride under the influence of alcohol/drugs? Always Occasionally Never

47 4.3 The proportion of accidents and injuries In Table 4, over 50% of the respondents had accidents. There was no significant difference in the frequency of accident between male and female respondents. The male respondents had an accident three to four times and more than five times compared to female respondents. However, the results were non-significant. The female respondents are likely to have an accident one to two times slightly more than males. The proportion of males and females that are likely to an injury as a result of motorbike is not significant. The number of the respondents who used motorcycle and have never had an accident did not respond to this particular question. I referred to them as never in table 4 Table 4 The Proportion of accidents and injuries (n=353) Variables Total (N=353) Sex P-value Total Male (n=184) Female (n= 169) Number (%) (%) Number (%) Have an accident when driving or riding a motorcycle No Yes How many times? 1-2 times time > 5 times Never Have you had an injury as a result of motorcycle No Yes The severity of the injuries Table 5 illustrates the estimate of the proportion of those who have had severe injury and the number of times the injury occurred. Males received injuries more than females and it was non-significant. The majority of injuries received while the respondents were passengers (78%). This was especially true for girls (96%). The results were statistically significant. Referred to question 26, the number of persons on the motorcycle did not matter whether two or more and there was a big differences among the respondents. Over 75.0% of the students said the cause of the accidents and injuries were due to alcohol, drugs, careless 35

48 driving, collision with other vehicles or motorcycle, the motorbike drivers were discussing on their cellphone while riding on the motorbike, high speed, loss of control, overtaking cars in a bend and some were untrained while 25.0% of the students said the accidents and injuries were due to bad roads, bad tyres of the motorbike, no brake stand on the motorcycle, no head lamp and also not respecting the road signs, poor technique and road traffic. This was nonsignificant (Figure 6). The majority of the respondents received an injury while they did not wear protective clothing like helmet, jacket and trousers especially among females. This was statistically significant. The proportion of the respondents that injured their leg was over 50%. The frequency of those respondents that had severe injury were slightly similar between males and females but was not statistically significant. Less than 50% of the respondents when to the hospital but 54% of them did not sleep in the hospital for one night while 46% of them slept in the hospital for one night or more. Main cause of accident and injury 25% Human 75% Vehicle and Environment Figure 6: The main cause of accident and injury (n=124) The distribution on how the accidents and injuries were found among drivers and passengers are illustrated on the diagram below. 36

49 Figure 7: The distribution of injury among passengers and drivers Table 5 The Severity of the injuries (n=124) Variables Total (N=124) Sex P-value Were you driving? Total Male Female Number (%) Number (%) Number (%) Yes No What protection did you wear? Helmet/Jacket/trousers None of the above Were you or the motorcycle rider under alcohol or drugs? No Yes Don't Know Which part of your body was injured? Head Leg hand Other Severity of the injury: No Yes Did you go to the hospital? No Yes

50 4.5 Association between accidents and motorcyclists background, knowledge and practice In the logistic regression males and females were analyzed together because of the small sample size. I was aware of the differences between males and females and adjusted for sex in the logistic regression. In the logistic regression univariate analysis variables that were not significant were dropped and not included in the multivariate analysis. However some of the socio demographic variables that were not statistically significant were also included in the multivariate analysis since the variables showed some interesting facts. In the univariate analysis, the female were more likely to be protected from accidents. In a stepwise logistic regression, the variable do you drive was found to be a confounding that was associated between sex and accident. This was not statistically significant. Hence, it was included in the multivariate analysis. The univariate analysis (Table 6) showed that there was higher probability of having an accident among respondents who rode motorcycles compared to those who did not. The respondents who did not rode were less likelihood of having an accident than those who did with OR 0.37 (95%CI: ) and with a p-value of (p<0.001) and it was statistically significant. After adjusting for all other variables the OR for those who did not ride were still of lower probability of not having accident compared with those who rode was 0.31 (95%CI: ) with p-value (p<0.000). This was statistically significant. The area of residence of the respondents is a major concerned. Those who lived in Tiko-Douala motorway were strongly associated with accident with OR 3.19 ( ). This was statistically significant. 38

51 Table 6 Association between accident and motorcyclists background, knowledge and practice Uni-variate analysis Sample size (n=353) Multi-variate analysis* Variables OR (95%CI) P-value OR (95%CI) P-value Sex: Male 1 (Reference) 1 (Reference) Female 0.88 ( ) < ( ) <0.481 Age: (Reference) 1 (Reference) ( ) < ( ) < ( ) < ( ) <0.901 Residence: Tiko 1 (Reference) 1 (Reference) Likomba 0.94 ( ) < ( ) <0.448 Tiko-Douala Road 3.04( ) < ( ) <0.020 Mutengene 1.39 ( ) < ( ) <0.474 Do you drive: Yes 1 (Reference) 1 (Reference) No 0.37 ( ) < ( ) <0.000 Wear protective clothing/helmet/boots Yes 1 (Reference) 1 (Reference) No 1.50 ( ) < ( ) <0.130 Wear bright/reflective clothing? Always 1 (Reference) 1 (Reference) Occasionally 1.14 ( ) < ( ) <0.690 Never 1.42 ( ) < ( ) <0.182 Ride while feeling tired Never 1 (Reference) 1 (Reference) Occasionally 1.44 ( ) < ( ) <0.063 Always 1.34 ( ) < ( ) <0.400 Ride while under the influence of alcohol/drugs Never 1 (Reference) 1 (Reference) Occasionally 1.81 ( ) < ( ) <0.189 Always 0.92 ( ) < ( ) <0.725 *This is adjusted for all other variables. 39

52 4.6 Association between injuries and motorcyclists background, knowledge and practice In Table 7 the logistic regression univariate analysis variables that were not significant were dropped and not included in the multivariate analysis. Nonetheless, some of the socio demographic variables that were not statistically significant were also included in the multivariate analysis since the variables showed some interesting facts. The OR for the female is 0.66 (95%CI: ) with p-value of (p<0.063) have the likelihood of not been involved in an injury in the univariate analysis. When adjusted with other variables they were still of less probability with injury. This was not statistically significant as well (Table 7). This area of residence of the respondents is of major concern. Those who lived in Tiko- Douala road are of higher probability with injury as a result of an accident. When adjusted for other variables the OR 2.52 ( ) and with a p-value (0.029) were of higher probability with injury as a result of the accident. This was statistically significant for those respondents who lived in Tiko-Douala road. The respondents who did not ride were less likely to have an injury as a result of accident than those who rode with OR 0.33 (95%CI: ) and with a p-value of (p<0.000). This was statistically significant. After adjusting for all other variables the OR for those who did not ride were still lower of having injury compared with those who rode was 0.33 (95%CI: ) with p-value (p<0.000) (Table 7). The findings in this study showed that the students were knowledgeable about the safety measures. Their practices were poor. Their knowledge was not equal to practice thou knowledge is equal to attitude and practice but this was not the case. This can be illustrated below: Figure 8: The Knowledge and Practice of the students 40