International Journal of Injury Control and Safety

Promotion

ISSN: 1745-7300 (Print) 1745-7319 (Online) Journal homepage: http://www.tandfonline.com/loi/nics20

Clothing-related motorcycle injuries in Pakistan:

findings from a surveillance study

Uzma R. Khan, Junaid A. Bhatti, M. Shahzad Shamim, Nukhba Zia, Junaid A.

Razzak & Rashid Jooma

To cite this article: Uzma R. Khan, Junaid A. Bhatti, M. Shahzad Shamim, Nukhba Zia, Junaid A.
Razzak & Rashid Jooma (2015) Clothing-related motorcycle injuries in Pakistan: findings from a
surveillance study, International Journal of Injury Control and Safety Promotion, 22:4, 308-313,
DOI: 10.1080/17457300.2014.908221

To link to this article: http://dx.doi.org/10.1080/17457300.2014.908221

Published online: 02 Jun 2014.

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 International Journal of Injury Control and Safety Promotion, 2015
Vol. 22, No. 4, 308–313, http://dx.doi.org/10.1080/17457300.2014.908221

Clothing-related motorcycle injuries in Pakistan: findings from a surveillance study

Uzma R. Khana, Junaid A. Bhattia,b,c, M. Shahzad Shamima, Nukhba Ziaa, Junaid A. Razzaka,d and Rashid Joomaa,e*
a
Department of Emergency Medicine, Aga Khan University, Karachi, Pakistan; bDouglas Hospital Research Centre, Montreal, Canada;
c
Public Health Solutions Pakistan (Pvt.) Limited, Lahore, Pakistan;
d
Aman Healthcare Services, Karachi, Sindh, Pakistan; eRoad Traffic Injury Research & Prevention Center, Karachi, Pakistan
(Received 16 November 2012; final version received 5 February 2014)

This study aims to assess the burden and patterns of clothing-related motorcycle injuries in Karachi, Pakistan. Data were
extracted from an ongoing traffic injury surveillance system. In three years (2007–2009), out of 99155 road traffic injury cases
there were 986 (0.9%) cases of clothing-related motorcycle injuries. Most cases were females (73.9%) and pillion riders
Downloaded by [York University Libraries] at 21:04 06 November 2015

(80.6%). The crashes involving clothing-related injuries were mostly single vehicle (98.5%), and largely resulted in injuries to
the external body (60.3%), limbs (51.0%), head (41.5%) and face (35.9%). One-third of injuries were either moderate (26.7%)
or severe (10.2%) while 10 (1.01%) deaths were reported. Female gender (11.4%), age
45 years (19.4%), pillion riding
(11.3%) and crashes occurring at intersections (12.3%) were more likely to result in moderate or severe injury as compared to
other users (P < 0.001). Injuries due to entanglement of loose fitting clothing in motorcycles are not uncommon in Karachi.
Awareness campaigns for prevention of such injuries may involve promotion of appropriate dressing for motorcycle riding
including close wrapping of clothes and encouraging installations of covers on the rear wheels and drive chains.
Keywords: clothing; South Asia; female; injury; pillion riders; motorcycle; Pakistan; scarf/dupatta

Introduction the sari, an unstitched length of cloth wrapped around the

Loose clothing with trailing ends has been reported to be
involved in injury to head, neck or other body parts by get-
ting caught in the moving parts of machinery such as fod-
der-cutting machines, electric grinders, crop threshers and
ridden vehicles (Aggarwal & Agarwal, 1998; Kaur, Gupta,
Sinha, & Shende, 2010; Shetty & Shetty, 2006; Siddiqui,
Shamim, Jooma, & Enam, 2006; Vaidya, Mathesul,
Panghate, Wade, & Sonawane, 2012; Verma, Aggarwal, &
Kohli, 2005; Zine, Tandle, Varma, & Jambure, 2011). Less
well documented are the hazards of loose clothing in road
use. Riders and passengers of two-wheeler and three-
wheeler vehicles in the South and East Asian region are
vulnerable to injury due to entanglement of the loose gar-
ments that are commonly worn (Agarwal & Agarwal,
2008; Aggarwal & Agarwal, 1998; Agrawal, Ninave,
Srivastava, Sunkara, & Agrawal, 2009; Chiu, Chan, Saw,
& Kwan, 2010; Gupta, Jani, & Datta, 2004; Siddiqui et al.,
2006; Verma et al., 2005). The shalwar–kameez is a tradi-
tional dress worn by both men and women particularly in
South Asia, consisting of a long shirt (kameez) worn over a
trouser (shalwar). Women, in addition, wear a long scarf/
dupatta to cover their heads or drape over their shoulders
while in the winters, men often drape themselves with
shawls (Habal, Meguid, & Murray, 1971). Moreover, tradi-
tionally oriented women wear long flowing abaya/burqa as
an overcoat. In some parts of South Asia, women also wear
waist with a long floating end draped over the shoulder.
Though previous reports showed that such clothing could
lead to injuries, the findings fell short in explaining the rela-
tive importance of this phenomenon beyond a few cases
(Aggarwal & Agarwal, 1998; Agrawal et al., 2009; Chiu
et al., 2010; Gowens, Davenport, Kerr, Sanderson, &
Marsden, 2003; Gupta et al., 2004; Jain et al., 2008; Kaur
et al., 2010; Kohli, Verma, & Agarwal, 1996; Shetty &
Shetty, 2006; Siddiqui et al., 2006; Verma et al., 2005; Zine
et al., 2011).
In the urban centres of the South Asia bereft of organ-
ised mass transport, extensive use of motorcycles is evi-
dent with attendant risk of entanglement of clothing by
those motorcyclists and their pillion riders wearing tradi-
tional loose fitting clothes (Aggarwal & Agarwal, 1998;
Agrawal et al., 2009; Siddiqui et al., 2006). This study
aims to assess the injury burden and patterns of clothing-
related motorised two-wheeler crashes in the major urban
centre of Pakistan. It also assesses whether females are
over-represented in clothing-related two-wheeler injuries.
Methods
Setting and design
The study setting is Karachi, which is the largest city of
Pakistan and the provincial capital of Sindh. It has an

*Corresponding author. Email: rashid.jooma@aku.edu

Ó 2014 Taylor & Francis

 International Journal of Injury Control and Safety Promotion 309

estimated population of 20 million. In Karachi, the num- clothing-related injuries), and by attributable risk propor-
ber of motorbikes was 1 million in 2010, and Karachi tion (Rockhill, Newman, & Weinberg, 1998).
Transportation estimates that there will be 3.6 million
motorbikes in Karachi by 2030 (Hasan & Raza, 2011).
The data regarding road traffic injuries were extracted Results
from an ongoing surveillance study launched by the Road
During the study period from January 2007 to December
Injury Research and Prevention Center in the Emergency
2009, the surveillance system recorded 99,155 cases of
Departments (EDs) of five major hospitals of Karachi
road traffic injuries including 11,146 females (11.2%).
including (1) Jinnah Post-Graduate Medical Centre, (2)
Almost two-thirds of those injured were either riders of
Abbasi Shaheed Hospital, (3) Liaquat National Hospital,
two-wheelers (n ¼ 42,576, 42.9%) or pillion riders (n ¼
(4) Aga Khan University Hospital and (5) Civil Hospital
16,412, 16.6%). Almost all riders were males (99.7%),
Karachi. The surveillance pro forma includes a list of
whereas females accounted for about 26.0% (n ¼ 4271)
mechanisms of injury with a specific mention of ‘clothing
of pillion riders. Of all riders and pillion riders, 986 cases
injuries’.
were clothing-related injuries; 795 (80.6%) were pillion
riders while 191 (19.3%) were riders. Overall, there were
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Case definition 729 females (73.9%) and 257 (26%) males; the female–
male ratio being 2.8:1. Figure 1 shows the gender-wise
In this study, a case was either a rider or pillion rider
percentage distribution according to the motorcycle-user
reporting to one of the participating hospitals with an
type. The risk ratio computation showed that female pil-
injury resulting from a vehicular crash due to inadvertent
lion riders were 31 times more likely to be involved in
entanglement of an article of clothing worn by either the
clothing-related motorcycle injuries than male pillion
rider or the pillion rider. The extracted cases are of inju-
riders (95% confidence interval ¼ 24.4 to 40.4). Further
ries reported from January 2007 to December 2009.
estimations showed that 96.8% of clothing-related injuries
in pillion riders could be attributed to female sex.
Data Clothing-related injury cases were predominantly
young aged less than 45 years (89.4%), 49.7% were
The case information includes gender, age, number of
19–34 years old and 20.6% were 5–18 years (Table 1).
vehicles involved in the crash, road-user type (motorcycle
Two-thirds of the cases were involved in crashes in mid-
rider or pillion rider), helmet use, type of location (inter-
block sections of the road. Only 1.4% of the cases
section or midblock), Abbreviated Injury Score (AIS) for
reported wearing helmets at the time of injury, and none
major body parts (i.e., head or neck, face, chest, abdomen,
amongst the females. Regarding disposition of the cases,
extremity and external) (Stevenson, Segui-Gomez,
10 deaths occurred in the ED; 107 (10.0%) cases were
Lescohier, Di Scala, & McDonald-Smith, 2001) and out-
admitted to the hospital, whereas the rest were discharged
comes (discharged, admitted or dead). This study consid-
from the ED. The case fatality ratio was 0.01. Figure 2
ered only ED-reported outcome which could lead to
shows gender-wise variation in the injury based on
underreporting of fatalities. Further details of the road
months. Most of these injuries in women occurred during
injury surveillance project are available elsewhere
the summer season between August and October, whereas
(Shamim, Razzak, Jooma, & Khan, 2011).
in males the increased injuries occurred in winter months
(October, November and January).
Analyses
The severity of an injury was assessed through computing
of the New Injury Severity Score (NISS), by means of
adding the squares of three highest injuries scored on the
AIS; NISS ranged from 1 to 75 (Stevenson et al., 2001).
Based on a previous study noting that NISS distribution
was skewed (Stevenson et al., 2001), the score was
divided into three categories: (1) mild injury, from 1 to 3;
(2) moderate injury, from 4 to 8; (3) severe injury, from 9
to 75. The associations of case characteristics with NISS
were assessed using chi-square test or Fisher’s exact test.
The overrepresentation of females in pillion riders’ inju-
ries was assessed by risk ratio, i.e., (female pillions cloth-
ing-related injuries ÷ total female pillion riders injuries) Figure 1. Gender and motorcycle-user type percentage distri-
 (total male pillion riders injuries ÷ male pillions bution of (2007–2009).
 310 U.R. Khan et al.

Table 1. Rider factors associated with injury severity in clothing-related motorcycle, Karachi, Pakistan (2007–2009).

All cases Mild (NISS 1–3) Moderate (NISS 4–8) Severe (NISS
9)

N % N % N % N % P-value

Gender <0.001
Male 257 26.1 187 72.8 54 21.0 16 6.2
Female 729 73.9 436 59.8 210 28.8 83 11.4
Age <0.001
0–4 29 3.0 28 96.6 1 3.4 0 0
5–14 75 7.7 49 65.3 19 25.3 7 9.3
15–18 95 9.9 61 64.2 30 31.6 4 4.2
19–24 198 20.4 129 65.2 53 26.8 16 8.1
25–34 284 29.3 188 66.2 65 22.9 31 10.9
35–44 186 19.2 122 65.6 49 26.3 15 8.1
45–70 103 10.6 43 41.7 40 38.8 20 19.4
Vehicles involved 0.28
Single vehicle 971 98.5 613 63.1 262 27.0 96 9.9
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Two or more 15 1.5 10 66.7 2 13.3 3 20.0

Road user <0.001
Motorcyclist 191 19.4 144 75.4 38 19.9 9 4.7
Pillion 795 80.6 479 60.3 226 28.4 90 11.3
Helmet wearing 1.00
Not wearing 417 98.6 295 70.7 92 22.1 30 7.2
Wearing 7 1.4 5 71.4 2 28.6 0 0
Location type <0.001
Intersection 277 28.9 175 63.2 68 24.5 34 12.3
Mid-block 682 71.1 431 63.1 187 27.4 64 9.4
AIS 1 AIS 2 AIS 3–5
Bodily region involvedy NA
Head 409 41.5 238 58.2 128 31.3 43 10.5
Face 358 36.3 309 86.3 47 13.1 2 0.6
Chest 10 1.0 5 50.0 5 50.0 0 0
Abdomen 13 1.3 8 61.5 2 15.4 3 23.1
Extremities 503 51.0 313 62.2 166 33.0 24 4.8
External body parts 595 60.3 584 98.2 9 1.5 2 0.3
Note: AIS – Abbreviated Injury Score; NA – not applicable; NISS – New Injury Severity Score.

Fisher’s exact test was computed by combining moderate and severe injuries.
yPercentages computed are for specific region.
The bold values indicate that the level of significance was set at less than 0.05.

One-third of the cases had either moderate (N ¼ 264,
26.8%) or severe (N ¼ 99, 10.2%) NISS. The female cases
had more moderate and severe injuries as compared to
males (11.4% vs. 6.2%, P < 0.001) (Table 1). Cases with
age
45 years had significantly more severe NISS; 19.4%
of them had severe NISS as compared to other age groups
(4.2%–10.9%, P < 0.001). Similarly, pillion riders were
more likely to have severe NISS scores (11.3% as com-
pared to 4.7% for riders). Finally, those involved in
crashes occurring at intersections had notably more severe
NISS scores of 12.3% as compared to 9.4% of those hav-
ing a mid-block crash.
In injuries, the common body parts involved were
external body, e.g., skin (N ¼ 595, 60.3%), limbs (N ¼
503, 51.0%), head or neck (N ¼ 409, 41.5%) and face
(N ¼ 358, 36.3%). One-tenth of head injuries were of
severe nature (10.5%). The head and face injuries
accounted for 9 of 10 deaths. Hospital admission reported
more injuries to head and face (
16.1%) as compared to
extremity injuries (11.0%).
Discussion
On average, one road traffic injury due to entanglement of
clothing in motorcycles occurred in Karachi each day.
Only few case reports relating to similar injury are avail-
able, and to our knowledge, this is the first surveillance-
based study describing the patterns of clothing related
injuries in a densely populated city. Previous reports from
South Asia explained that such injuries resulted from
entanglement of scarves in a motorcycle’s moving parts,
exerting an abrupt strong traction effect on rider/passen-
ger and resulting in an injury with or without a vehicular
crash (Jain et al., 2008; Siddiqui et al., 2006).
Though just 11% of all road traffic injuries recorded
by the surveillance system in Karachi occurred among
 International Journal of Injury Control and Safety Promotion
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Figure 2. Monthly pattern of clothing injuries in Karachi, Pakistan (2007–2009).
female road users (Shamim et al., 2011), nearly three-
quarters of the clothing-related motorcycle injury cases
are female pillion riders, making this an important public
health issue affecting road users of the female gender.
Deficiencies of public transport and high fuel costs con-
strain low-income families to use motorcycles as a conve-
nient and cost-effective family transport medium
(Krishnan & Smith, 1994). Without deployment of mass
transport, motorcycles on the road could triple by 2030
(Hasan & Raza, 2011), and such injuries could become an
even more significant health burden of female road users.
In Pakistan, females usually do not ride motorcycles
by themselves and use them as a pillion rider accompa-
nying males. Susceptibility of female pillion riders to
clothing-related motorcycle injury is due to their loose fit-
ting and baggy garments along with the wearing of scarf/
dupatta and abaya, particularly in the summer. Moreover,
female pillion riders sit on the bike in a side-saddle man-
ner (Khan, Zia, Awan, & Khan, 2011), with their tradi-
tional scarf/dupatta wrapped around their necks dangling
directly in front of the spokes of the back wheel, thus
making them more vulnerable to entanglement and injury
(Siddiqui et al., 2006). The crashes caused by entangle-
ment of the female clothing results in injury not only to
them but to the rider of the motorcycle, and in some
instances to the child passengers. Moreover, male motor-
cyclists might be involved in injuries due to the common-
place wearing of baggy trousers and long shirts. In winter,
numerous male riders drape themselves with long shawls,
which can be entangled in wheels.
In addition to this, there are motorcycle-related factors
involved in such injuries. Many older motorcycles have
their drive chains uncovered, and this can cause
311
entanglement of clothing, especially involving lower end
of baggy trousers (shalwar). Previously, D’Souza et al.
(1996) and Segers, Wink, and Clevers (1997) proposed
using wheel covers to prevent foot and ankle injuries due
to bicycle spokes. Motorcycle wheel covers could serve
the same protective function against clothing entangle-
ment, but it is not a standard feature of most locally avail-
able motorcycles. In some instances, motorcycle wheel
covers are available as an accessory (Gowens et al.,
2003). There are, however, no defined standards in Paki-
stan to ensure their quality and effectiveness. The magni-
tude of the problem that this study highlights should serve
to advocate the incorporation of these design features in
motorcycles during manufacturing, and to ensure that ven-
dors are selling safe motorcycles in the South Asian
markets.
In this study, the head and face injuries were common
which might be explained by low helmet use (Ghaffar,
Hyder, & Masud, 2004; Khan, Khan, Aziz, Islam, & Shaf-
qat, 2008; Shamim et al., 2011) and, in particular, female
helmet use was vanishingly rare (Khan et al., 2011).
The lack of awareness regarding the use of a helmet and
the laxity in implementation by law-enforcing agencies
are the crucial factors behind low helmet use. The quality
of available helmet could also be of concern as reported
previously (Peden et al., 2004).
This study has a number of limitations. First, this
being a facility-based study did not cover the traffic inju-
ries of the entire city. Previous investigations estimated
underreporting of traffic injuries in facilities to be around
half of the actual injuries (Bhatti, Razzak, Lagarde, &
Salmi, 2011; Razzak & Luby, 1998). This means that
there could be more clothing-related injuries in Karachi
 312 U.R. Khan et al.
that had occurred during the study period, and possibly
unaccounted in this study. Second, fatalities might be
underreported herein as this study only considered the out-
come at ED management. Furthermore, the cases were not
followed for disabilities. Previous studies had mentioned
that motorised three-wheelers could also result in similar
injuries (Aggarwal & Agarwal, 1998; Kohli et al., 1996;
Verma et al., 2005), but this study did not include such
injuries. In addition, this study lacked the details about
vehicle condition and speed before the crash to assess
whether these factors contributed to increased crash risk
and injury severity. Finally, though this study attempted
to quantify the gender-based risk differences, the risk of
underestimation of female involvement in clothing-related
injuries remains. More accurate estimations about female
over involvement can only be estimated if motorcycle rid-
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ing surveys are available for males and females. Nonethe-
less, study showed that female pillion riders should be the
focus of prevention campaign for such crashes.
Conclusion
On average, one motorcycle-related clothing injury occurs
each day in Karachi. Female pillion riders are particularly
vulnerable to these injuries. The traditional baggy clothes
with loosely draped scarf/dupatta are a major hazard in
South Asia for those riding motorcycles. In view of the
dearth of literature on prevention of clothing-related road
traffic injuries, the findings from this study provide the
imperative for adoption of relevant interventions to pre-
vent such injuries. First, the public needs to be aware about
the injuries caused by loose clothing along with the impor-
tance of wearing helmets. Second, there is a need to edu-
cate road users, particularly females so that they do not
wear loose clothes or trailing scarves/dupatta while using
motorcycles but rather that they wear scarves of lesser
length or properly wrap and tuck these to eliminate dan-
gling ends. Third, local motorbike manufacturers could be
informed of the burden of clothing-related injuries in order
for them to develop purpose-designed covers for the rear
wheel and effective encasement of the motorcycle’s drive
chain. The feasibility of these interventions and their effec-
tiveness, however, remains to be investigated.
Acknowledgements
A note of thanks to Mr Ameer Hussain and Mr Kamran Karamat
of the Road Injury Research and Prevention Center for assistance
in access to the data of the ongoing injury surveillance project of
Karachi.
Funding
U.R. Khan and J.A. Razzak were partially supported through the
“Johns Hopkins-Pakistan International Collaborative Trauma
and Injury Research Training program”, [grant number D43-
TW007-292] from the Fogarty International Center of the United
States National Institutes of Health. The content is solely the
responsibility of the authors and do not represent the views of
Fogarty or NIH.
The Road Traffic Injury Research and Prevention Centre, in its
first three years of functioning, was in part supported by grants
from Indus Motor Company Ltd., the World Health Organisation
Regional Office for the Eastern Mediterranean Region and the
Aman Foundation. Funding agencies had no inputs in study
design, conduct, analyses, interpretations of results and decision to
submit manuscripts.
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