Beruflich Dokumente
Kultur Dokumente
Dr. N.S.Vishwanath
Thiruvananthapuram, Kerala
October 2010
Acknowledgements
First I would like to thank the Almighty for all that I have and my Parents for all
that I am.
This research would not have been possible without the untiring and unflinching
support of my guide Prof. Raman Kutty. He has been a beacon of light ever since I
have met him and has always been a source of inspiration and knowledge.
I would also like to express my sincere gratitude to Dr. Mala Ramanathan and Dr.
Manju Nair, who have been of utmost help from the very beginning of this study.
Dr. P.S. Sharma has undoubtedly been the best teacher I have come across and I
thank him for his wonderful lessons in Biostatistics.
I would also like to thank Dr. K.R. Thankappan and all other faculty members at
AMCHSS for their constant encouragement and valuable comments during the
entire process. I express my indebtedness to Dr. Sundar Jayasingh who has been
most helpful throughout the course.
My Colleagues Uma, Sony, Sourabh and Palash along with our hostel mate
Sabarinath have strived very hard all along to help me at various stages of this
study. Also I express my sincere and heartfelt thanks to the person who would
prefer anonymity but has been supportive from the very nascent stage of my
study.
If I am able to put my pen on paper today it is because of all the participants in my
study and also the contributions of a lot of other people, all of whom I may not be
able to acknowledge, but my sincere gratitude shall always remain.
Chapter 2 METHODOLOGY
2.1 Study Design…………………………………………………………………………….22
2.2 Conceptual Framework………………………………………………...........................22
2.3 Cross Sectional Survey:
2.3.1 Study Setting……………………………………………………...........................23
2.3.2 Sample Size………………………………………………………………………..23
2.3.3 Sample Selection…………………………………………………………………..23
2.3.4 Data Collection……………………………………………………………………23
2.3.5 Data Storage……………………………………………………………………....23
2.3.6 Data Analysis and Statistical Measures………………………………………....23
2.3.7 Scale for „Risk Perception‟……………………………………….........................24
2.3.8 Variables used…………………………………………………….........................25
2.3.9 Operational variables………………………………………………………….…25
2.4 Content Analysis:
2.4.1 Content Used……………………………………………………………………...28
2.4.2 Inclusion and Exclusion criterion……………………………………………..…28
2.4.3 Procedural flowchart…………………………………………………………..…28
2.4.4 Data collection and storage ……………………………………………………...28
2.4.5 Reporting the result……………………………………………………………....28
2.5 Key Informant Interviews:
2.5.1 Sample Selection…………………………………………………………………..29
2.5.2 Sample Size……………………………………………………………………..…29
2.5.3 Data Collection and storage……………………………………………………...29
2.5.4 Data Analysis……………………………………………………………………...29
2.5.5 Stakeholder Analysis…………………………………………………………..…29
2.5.6 Reporting the result……………………………………………………………....30
2.6 Triangulation…………………………………………………………………………....30
2.7 Ethical Considerations:
2.7.1 Risks to the participants………………………………………………………….30
2.7.2 Privacy and confidentiality……………………………………………………....30
2.7.3 Benefits…………………………………………………………………………....31
2.7.4 Informed consent processes …………………………………………………..…31
Chapter 3 RESULTS
3.1 Cross sectional survey:
3.1.1 Helmet wearing behavior in the sample…………………………………………32
3.1.2 Risk perception in the sample……………………………………........................32
3.1.3 Sample characteristics………………………………………………………....…33
3.1.4 Reasons cited for observed helmet wearing behavior………………………….37
3.1.5 Risk perception as a predictor for helmet wearing…………………………….37
3.1.6 Significant findings from bivariate analysis………………………………….....38
3.1.7 Inferences…………………………………………………………………………38
3.1.8 Multivariate analysis……………………………………………………………..38
3.2 Content analysis
3.2.1 Number of reports………………………………………………………………...39
3.2.2 Reports on policy……………………………………………………………….…40
3.2.3 Historical perspective of policy………………………………………….……….40
3.2.4 Other reports on helmets…………………………………………........................41
3.2.5 Themes derived…………………………………………………………………...41
3.2.6 Distribution of themes over time …………………………………………….….42
3.2.7 Interpretation of themes……………………………………………………….…43
3.2.8 Overall interpretation……………………………………………………….……43
3.3 In-depth interviews
3.3.1 Stake holder analysis……………………………………………………………..44
3.3.2 Themes derived…………………………………………………………………...46
3.3.3 Theme-wise opinions…………………………………………………………..….46
3.3.4 Interpretation……………………………………………………………………..46
Chapter 4 DISCUSSION AND CONCLUSION
4.1 Discussion
4.1.1 Cross-sectional survey…………………………………………………………....50
4.1.2 Content analysis…………………………………………………..........................53
4.1.3 In-depth interviews……………………………………………………………….54
4.1.4 Triangulation…………………………………………………………………...…56
4.2 Strengths of the study............................................................................................................59
4.3 Limitations of the study…………………………………………………………………….59
4.4 Recommendations and policy implications of the study………………………………....60
4.5 Conclusion………………………………………………………………………………..…60
REFERENCES
APPENDICES
Appendix I: Consent form for cross-sectional survey
Appendix II: Consent form for In-depth interview
Appendix III: Interview schedule for cross-sectional survey
Appendix IV: Scale for risk perception
Appendix V: Checklist for content analysis
Appendix VI: Interview guidelines for policy makers
Appendix VII: Interview guidelines for policy implementers
LIST OF TABLES:
LIST OF FIGURES:
Introduction: Motorized two wheeler riders are especially vulnerable to road traffic accidents
with head injuries being the major cause of death and disability. Studies from across the globe
have conclusively proved that any universal helmet law when implemented properly increased
the helmet use substantially bringing along with it a reduction in mortality and morbidity due to
head injuries.
Methodology: It is a mixed methods study consisting of three components. The first is a Cross
Sectional Survey of 300 two-wheeler drivers in Thiruvananthapuram City. The second
component is content analysis of newspaper reports pertaining to helmet legislation from the
Thiruvananthapuram edition of two leading newspapers during two periods of two years each.
The third and final component was to conduct in depth interviews of key stakeholders in helmet
policy of the state.
Results: The study has found 36.8 percent drivers of the respondents to be wearing helmet. Risk
perception was found to be ‘poor’ among 55.3% of the respondents. Those with poor risk
perception were 4.3 times likely to not wear a helmet. Those ever fined were two times likely to
not wear helmet when compared to those never fined.
Content analysis of the two newspapers found that reports pertaining to ‘voice of dissent’ were
the most frequent. The trend of reporting though has changed over time and it was also found
that media reports had a role to play in the policy making process.
Conclusions: This study calls for a strong inter-sectoral co-ordination, to deal with shortage of
manpower, a positive role from the media and better strategies to improve awareness. It has also
come out with specific policy recommendations and seeks further research on this topic.
Chapter 1 INTRODUCTION AND REVIEW OF LITERATURE
Injury is defined as “damage or harm caused to the structure or function of the body
that injuries account for nearly 9% of the global mortality while a large proportion of
those surviving injuries end up with temporary or permanent disabilities. Injuries may be
broadly classified into Intentional and Unintentional. Intentional injuries usually arise out
of violence which may be self inflicted or acts of assault and war, all of which are
completely avoidable. Unintentional injuries, as the name suggests, are usually accidental
in nature. .
occurs in a particular time and place, with no apparent and deliberate cause but with
marked effects. It implies a generally negative outcome which may have been avoided or
prevented had circumstances leading up to the accident been recognized, and acted upon,
prior to its occurrence. Among them, road traffic accidents are said to the most common
cause for hospitalizations across the world. Though all accidents may not be completely
avoidable, efforts can certainly be made to reduce the impact of such accidents. In spite of
all this, injuries and accidents have not been the highest priority while making policies of
public protection. This attitude may also stem from the human tendency to classify
anything common as being normal. Epidemiologists like to believe that such accidents are
rather „predictable and preventable‟ events. Good planning and safety measures may not
be able to „predict‟ and „prevent‟ all accidents but can substantially reduce the number of
1
Road safety is an important issue and of high priority. It is more pertinent in regions of
the world which are experiencing a sudden explosion in urbanization and motorization. A
country like India is typical of this phenomenon where there is a huge increase in the
„middle class‟ which comes with a high level of purchasing power. People seem to prefer
A huge rise in the number of two-wheelers in the roads is a common problem afflicting
several countries in the world. Unfortunately though, our roads are not meant to handle
such high numbers and we are witnessing a surge in the road traffic accidents. In India as
well as in most other Low to Middle income countries, after pedestrians it is the two
wheeler riders who are involved in most of the road traffic accidents. These accidents are
both predictable and preventable. All that is needed is a good policy and proper
implementation along with an increased awareness among the populace. Most of the
deaths and injuries in accidents involving two wheelers are due to head injuries. One
simple and effective mechanism of preventing several such deaths and injuries is to make
India does have a legislation making it mandatory to wear helmets while riding motorized
two wheelers. But the problem is with the implementation, which apart from being
lackadaisical, also varies from region to region. The moot issue though is, if people are
protected by wearing helmet why don‟t they just wear it. Most of the people say helmets
are very uncomfortable to wear while another factor may be lack of awareness. It is for
the policy makers to see how people can be made more aware while the role of media in
2
Humans by their very nature are „risk takers.‟ But how much of a risk will a person take,
varies from individual to individual. Factors such as gender, education, culture, class, etc.
may have a bearing on this. An individual may take different amounts of risk in different
times and in different situations. Thus venturing out in a two wheeler without wearing a
safety helmet may vary from person to person and situation to situation. All this depends
on how the person at that time and in that situation perceives the risk. There is a
substantial scope for research on risk perception, its determinants and its effects.
Policy is ever evolving and based on evidence. Helmet legislation and its implementation
vary across the globe. In India, there is a policy in place but not uniformly implemented
across the country. Kerala has a unique rule which says that pillion riders are not required
to wear helmets, which certainly is not based on any evidence. There is a need to study
how the policy has evolved over time and also to learn from the experiences of other
regions.
1.2) Injury
Injury is a major health problem worldwide. In 2005, the United States saw 173,753
persons losing life on account of injuries and 1 in every 10 person is said to have
experienced a non fatal injury requiring hospitalization. Although injuries do not often
result in death but, they place a considerable burden on the individual, his family and the
society as a whole. The statistics from US also point that more than 37 percent of all
deaths due to unintentional injuries are through Motor Vehicle Accidents, which also
accounts for 14.3 percent of all not fatal and unintentional injuries.1 Injuries are a huge
3
burden in India also. Though there is no single source for the figures, various reports
compiled by the National Crime Record Bureau suggests that in 2001 there were
2,710,019 deaths due to accidental injuries. Out of this, road traffic accidents accounted
for 353,100 injuries and 80,262 deaths. A review of the studies done in India states, for
every death due to injury there are 50 others with minor injuries2.
The agenda of research in this field has been identified as a critical priority by the Centers
for Disease Control, which suggests going forward in a step wise manner. First, we have
to describe the problem and delineate the demographic characters of the people involved.
Then we have to find out why the injuries occur and to determine its causes and
correlates. This should lead us to find the potential strategies for injury prevention which
disseminate the research which encourages the communities and policy makers to adopt
The WHO global burden of disease project estimates that 1.27 million people died as a
result of road traffic collisions in the year 2004. Almost 75 percent of these deaths are
among men and what is definitely worrying is the fact that the highest impact is in the
More than 90 percent of these deaths are said to be in the low and middle income
countries which are said to have only 48 percent of the total vehicular population though.
4
10 countries contribute to nearly 62 percent of these moralities and India has the dubious
Even developed countries are grappling with this problem and in a country like Sweden;
road traffic crashes are responsible for 20 percent of deaths among children between five
to 19 years.
The most vulnerable group for road traffic injuries is identified as pedestrians, cyclists
and those using motorized two and three-wheelers. They account for 46 percent of the
In an already bad scenario, the situation in India is further grim. A rough estimate puts the
figures as 1,50,000 deaths and 2.8 million hospitalizations for the year 2010 which is
further said to increase over the coming years. Road traffic injuries are next only to
A review of the literature on road traffic injuries in India concludes that there is a definite
lack of population based research and those available are highly heterogeneous. It calls
for road traffic injuries to be taken as a major research agenda in this country and this
Among the few available articles, one calls for increased participation of health
professionals towards rectifying the situation through health promotion and increased
5
Another states that countries like India are to „leap frog‟ from this situation and
immediately incorporate the currently available best road safety practices (Sethi D, Zwi
A, 1999).7
Even within India, states with rapid motorization are witnessing the larger share of deaths
and injuries. A state like Kerala, which has the highest road density in the country, is
facing a situation which is further grim. The total reported cases of accidents in the state
for 2008 is 37263 which led to 3901 deaths and 43857 people injured8; this is while
Again, the point to be reiterated is the avoidability of this loss. A study from Iran
attributes the success of its nationwide campaign to strict law enforcement and mass
education campaigns.9
In an effort, which could not have been timelier, the first ministerial conference on road
safety met at Moscow in November 2009 and the „Moscow Declaration‟ was made. They
agreed to the fact that road safety is a „cross cutting‟ issue which can contribute
significantly towards achieving millennium development goals and the need for a
comprehensive action. Some of the salient features of the resolution were to encourage
implementation of the recommendations made by the World report on road traffic injury
prevention and to reinforce government leadership, allowing them to set ambitious yet
feasible national road traffic casualty reduction targets. The declaration also invites the
United Nations General Assembly to declare the decade 2011 to 2020 as the “Decade of
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1.4) Motorized two wheelers
India has been seeing phenomenal economic growth over the past couple of decades. This
has led to a burgeoning middle class with huge spending power. The lop side has been a
phenomenal growth in the number of two-wheelers on the road. In India, three fourth of
registered vehicles are motorized two-wheelers. This greater number has obviously led to
an increased risk of exposure to road traffic crashes. Two-wheeler drivers and pillion
account for 38 percent of deaths and 51 percent of injuries among all casualties due to
road traffic crashes. In the year 2007, the National Crime records bureau puts the number
An Epidemiological study done in south India says that among motorized vehicles, two-
wheelers were most involved in accidents (31.1 percent) and were also the leading cause
towards pedestrian injuries (24.4 percent).13 Thus, it is highly pertinent that we further
Motorcycle accidents result in more serious injuries than motor vehicle accidents because
of limited safety precaution and the difference in injury mechanism. A study from
California finds that the percentage of fatal injury crashes among motorized two-wheelers
It is not only death which is worrying but also the long term disability involved among
those who survive such crashes. A study done at Florida to find the outcome of
motorcycle riders one-year post injury puts forth some startling facts. Though 86 percent
of the victims had returned back to work, only 27 percent had started using motorcycle
7
again, while 51 percent were still grappling with physical deficits and 44 percent of them
In India too certain studies have been done to find the impact of motorized two-wheeler
accidents. A one year post injury survey finds that only 70% of urban and 54% of rural
people were able to return to their jobs and had noticed a 20% decline in income levels
compared to pre injury status.16 The economic burden of such an injury costs the family
Two-wheelers being smaller in size and not highly visible on the road make the rider
particularly vulnerable to crashes. In the event of a two-wheeler crash, the head of the
driver or pillion directly hits a mobile or immobile object causing injury. Several studies
point to the fact that head is the most commonly injured organ among two-wheeler
occupants in case of crashes. It is found that about 40 to 50 percent of those injured and
more than one-third of those killed in two-wheeler crashes are found to have sustained
During a motorcycle crash, the rider is thrown forwards / backwards or falls to the side
hitting an object depending on collision patterns. When a rider's head hits an object, the
forward motion of the head is stopped but the brain continues to move until it strikes the
inside of the skull. It then rebounds hitting the opposite side of the skull. The resulting
damage can vary from minor head injuries to instantaneous death depending on the
unprotected, the amount of energy transfer will be much higher and injuries severe.
8
1.5) Helmets
One important way of protecting head and brain injury is through wearing helmets. A
helmet primarily reduces the impact of the collision and thereby consequent injury to the
brain by acting as a mechanical barrier between the skull and the impacting object. It
reduces the deceleration of the skull, provides a cushioning effect and spreads the force of
Helmets have been proved effective through various studies. A study done in Taiwan
points that helmet use could save up to five Quality Adjusted Life Years (QALYs) among
motorcyclists sustaining head injuries.20 Another study from the US states that the relative
risk for death, after adjusting for other variables, for a helmeted rider as compared to a
A manual released by the World Health Organization (WHO) explicitly states the
effectiveness of helmets, based on systematic review of findings from across the globe.
Wearing of helmets is said to reduce the risk and severity of injury by 72 percent,
decrease the likelihood of death by 39 percent and apart from these, also substantially
The WHO manual advices policy makers to consider measures that increase the use of
helmet which may be through proper legislation, enforcement and community education
campaigns. It is also pertinent to mention that various designs and styles of helmets have
9
been recommended depending on the needs and conditions of various regions in the
world.19
But at the same time, policy makers especially from LMIC countries have to consider the
pricing of helmets. Before any such universal helmet legislations, governments also have
to ensure that standard helmets are made available and enforcement is at a level to ensure
usage.22
Experiences across the globe in matters related to universal helmet legislation have been
mixed. Studies show that there has been an increase in helmet wearing practices among
two-wheeler riders after a law has been implemented. There is also a simultaneous
involved in accidents.23, 24
A study from Florida puts the figures at over 30 percent
decrease in fatalities.25 Apart from similar findings, a Taiwanese study also conclusively
found a decrease in the length of hospital stay and severity of injury.26 In Maryland,
motorcyclist fatality rate is said to have dropped from 10.3 per 10000 registered
motorcycles pre law to 4.5 post law despite almost identical numbers of registered motor-
cycles.27 Also the economics seem to work in favor of having universal helmet
legislation. It is potentially one of the most cost effective interventions especially in the
context of LMIC.28, 29
An interesting study from Viet Nam finds that children wear
helmets in much lesser numbers as compared to adults. Fear of neck injury among them
and non availability are some of the reasons cited. This is a factor which has to be
10
1.6.2 How law should be enforced:
But enforcing a law has never been an easy proposition wherever it has been tried.
Making legislation has been always easy but for proper implementation, we need a
successful it should be population based and not require individual initiatives. Also it
should be passive rather than requiring active participation and should be accomplished
with a single action rather than requiring repeated reinforcement. A law requiring
motorized two-wheeler riders to wear helmet, does not incorporate any of these
There have also been widespread protests witnessed against universal helmet legislations.
An interesting case is of the US. This country initially adapted a universal legislation
throughout the country but had to later succumb to demands from various quarters. They
ultimately gave discretionary powers to each state and allowed them to decide whether or
not they wanted such legislation in their respective states. Each of the states had a full
law, a partial law or no law pertaining to helmet at all. In 2008, only 20 of the 51 states
had universal helmet legislation. Most of the protests were not scientifically based but
rather questioned the basis of the assertion that helmet wearing was an effective
intervention. The present situation is attributed mainly to activism and lobbying by rider
groups which were successful after the debate moved to state legislatures. This was
despite the fact that most scientific findings advocated universal law.33, 34 A comparative
study done between states with full law and states with partial or no law has some
interesting findings. Although the median death rate due to two-wheeler accidents is more
in states with full law but when adjusted for other factors such as population density and
11
weather, the findings point towards a lower death rate in states with full law.35 A cross
sectional time series data collected from the 50 states and District of Columbia for the
period from 1975 through 2004, universal helmet laws were associated with an 11.1
The Indian situation is vastly different and is to be seen from a different plane. We have a
heterogeneous traffic ranging from pedestrians and animal-drawn carts to buses and
trucks. Also all of them share the same roads. All this is further compounded by an ever
increasing traffic population and the resulting accidents. It is estimated that the cost of
traffic accidents constitutes 3 percent of the country‟s GDP. In this situation, riders of
Though there is much scope for further research, but even existent findings point towards
the fact that it is pertinent for India to have universal helmet legislation. India indeed does
have one. Article 129 of the Central Motor Vehicles Act states that every person either
driving or riding pillion in a motorized two wheeler must wear the safety helmet. Also
standards have been set for the quality of helmets to be used. This legislation is uniform
at the stage of implementation where we lag thus leading to the existent levels of dismal
usage.
Awareness building is also an important mechanism to make people wear helmets but it
cannot be used in isolation. Notification of the law and subsequent enforcement by police
agencies is a population based strategy is likely to be more effective where people still
12
Though not too many studies have been undertaken in the Indian context, several studies
have been undertaken by the National Institute for Mental Health and Sciences. They
point that after proper implementation of universal helmet law in parts of the country,
percent. All these point towards a necessity to notify and implement the law without
delay. 38, 39
There have been several reasons cited to why people do not wear safety helmets while
riding a motorized two wheeler and they vary across regions. The major factors cited in
South Asia have been physical discomfort, decreased vision and inability to hear. They
are partially true but certainly do not over-weigh the safety provided by wearing a helmet.
Improved designing and ensuring availability of the recommended design shall certainly
A study done in the Indian state of Kerala found that 31.4 percent of two-wheeler riders
reported of using helmet. It found that females are more likely to wear helmet as
compared to males and those who were unmarried are 2.3 times likely to wear helmet as
compared to those married. Surprisingly, those who consume alcohol are 1.3 times likely
to wear helmets but people who have reported of no drunken driving behavior amongst
them are 3.7 times likely to wear helmet. At the time of interview for the study, 26.9
13
1.6.6 Behavior of helmet wearing:
There are other findings on determinants of helmet use from across the globe. One study
from Italy finds that helmet use was greater for adolescents from households in which at
least one family member wore a helmet.42 A knowledge, attitude and practice study done
among Nigerian motorcyclists, finds lack of adequate knowledge leading to poor practice
of road safety measures including helmet wearing.43 But a study done in Southern China
found that though the levels of awareness about benefits of helmet wearing were high, the
observed helmet use was low. It goes on to suggest that interventions should be made
Voices have been raised at the apathy shown towards this law. It has been pointed out that
we all carry the burdens of human and economic waste caused by damage to people that
takes place in the public-in this case, our streets and highways. We all have a right, even
an obligation, to take steps to reduce the damage and its consequences.45 But still the
history. The form of defiance shown by two-wheeler riders in not wearing helmet are
conscientious and especially in a democratic set up, a person may also ask for his right to
disobey.46 A qualitative study done through in depth interviews and focus group
discussions from Iran, looking into the motorcyclists‟ reaction to safety helmet law comes
out with interesting results in the form of themes representing the modes of disobedience
This study also calls out for further research into how risks are perceived by the two-
wheeler riders. It feels that how a person perceives the risk involved may have a strong
14
1.7) Risk Perception
The importance of behavior in prevention of injuries has been well documented. Attitudes
are „tendencies to evaluate an entity with some degree of favor or disfavor, ordinarily
strong relation with the behavior, attitudes are also influenced by the risk perception. The
hostility, was originally developed in relation to coronary heart disease. It has also been
Perception of risk is a well documented and studied subject, especially with regards to
risks involved with smoking and the behavior patterns. There is empirical evidence to
suggest that not only does the risk perception have a strong influence on the risky
behavior but also that the perceived risks are generally biased compared to the objective
risk. It is also found that even when risk perceptions were low, those with higher efficacy
1.7.3 Modeling the relation between risk perception, attitude and behavior:
The Expected Utility (EU) model, introduced in the seminal work of von Neumann and
Morgenstern (1944) is the classical model of decision under risk. The Rank-Dependent
Expected Utility (RDU) model (Quiggin 1982, Yaari1987) was built as an attempt to
answer some of the criticisms to the EU model. This explains the relation between Risk
perception, Risk attitude and the decision or the behavior. Though a pretty robust model,
15
it is said to be not dynamically consistent. It is suggested to use recursive models such as
At the level of the individual, perceptions would determine whether or not appropriate
actions will be taken. At the societal level though, it would drive the agenda of regulatory
Risk perception has been a focus of interest for policy makers and researchers; it holds a
central position in the political agenda of several countries. But risk perception still
specifies that there are four types of people with different concerns: the egalitarians who
are concerned about the hazards of technology and environment; the individualists who
are concerned about war and other threats to the market; the hierarchists who are
concerned about law and order; and the fatalists who are concerned about nothing. Some
of the factors which are said to have an effect on the risk perception of an individual are
sex, education, income, size of residential community and political party preference.52
Gender structures, reflected in gendered ideology and gendered practice, are said to give
rise to systematic gender differences in the perception of risk. These gender differences
may be of different kinds, and their investigation requires the use of qualitative as well as
quantitative methods.53
16
1.8) Media and its role
Media also has an important role to play towards helmet legislation. Media‟s influence in
changing the perceptions and hence the behavior is huge. In a state like Kerala media,
especially the print media has an important role to play. In most cases the choice of media
is also strongly affected by the political preference of an individual. A study done in Viet
Nam points that with the successful implementation of the legislation, the functions of the
print media in promulgating and promoting the legislation, together with the reporting of
ongoing resistance to the process; serve to enable a dialogue between the State and
issue, the media have identified a potential ongoing role in monitoring the state‟s
initiative.54
Law has been a major public health tool since time immemorial. Interventional public
health laws are crafted to address specific health conditions or risk factors. A systematic
review of the universal helmet law recommends policy makers to adopt this in their
There are certain specific concerns to be addressed while formulating a policy towards
universal helmet legislation. The case of the US has a lot of lessons be learnt from. It
reflects the extent to which concerns about individual liberties have shaped the public
laws reduce fatalities and serious injuries, only 20 states currently require all riders to
17
wear helmets. During the past 3 decades, federal government efforts to push states toward
enactment of universal helmet laws have faltered, and motorcyclists‟ advocacy groups
have been successful at repealing state helmet laws. There were motorcyclists who argued
in court that the law deprived them of their rights and won. This history of motorcycle
helmet laws in the United States illustrates the profound impact of individualism on
American culture and the manner in which this ideological perspective can have a
crippling impact on the practice of public health. The success of those who oppose such
statutes shows the limits of evidence in shaping policy when strongly held ideological
commitments are at stake. The challenge for public health is to expand on this base of
justified paternalism and to forthrightly argue in the legislative arena that adults and
adolescents need to be protected from their poor judgments about motorcycle helmet
use.57
Another thing to look out for is some special-interest lobbies which frequently influence
legislation and regulations in ways that not only are detrimental to the public good but
also reduce the freedom of many individuals. Freedom not to wear helmet is extolled by
special interest groups in pursuit of their own objectives. They ignore the fact that it
would entail important losses of other people's freedoms. Public health professionals have
But the counter argument is that the unqualified call for public health officials to put a
stop to injury and disease losses resulting from the practice of individual freedoms is
quite disturbing. For every law and regulation there is a judgment to be made both by
18
public officials and by the consuming public as to what constitutes a reasonable risk as
any policy, all the stakeholders should be included to discuss the various aspects. Many a
times, only scientific evidence cannot formulate policies, it has to be inclusive and
An interesting case looking into individual rights versus the public health is the case of
Jacobson had refused to be vaccinated against small pox during the mandatory
vaccination campaign and had been convicted for this. The courts upheld the conviction
saying that states may limit individual liberty in the service of well-established public
health interventions.
Each such legal measure limits the rights of individuals in the name of public health, and
each is widely accepted as an important tool by the public health community. We have
come to recognize that although states may restrain liberty in order to protect public
Policy is never static, it is ever evolving. To strive towards improving policies should
always be the policy makers‟ agenda. In this context we should try to learn from the
experiences around the world. The European commission set up a committee to come up
with suggestion on how public health policies. One of the five chapters in the final report
deals with accidents and injuries. It outlined areas where legislation, regulations and the
setting of standards might promote safety, and other areas where more dissemination of
information and advocacy measures might be appropriate. It also called for development
19
of health data systems in the field of accidents and injuries, identified areas where
training should be developed, and also indicated particular research priorities in this
field.61 India too should set up such a committee to come with comprehensive
recommendations.
Another interesting case study is the effective implementation of a national helmet law at
Viet Nam. It identifies political leadership, intensive advanced public education and
stringent enforcement as the three factors for its success. Also the role of media has been
appreciated.62
A study was done to analyze the road safety issues discussed by members of the Indian
Parliament during the period from 2002 to 2004 and tries to find the gaps the need to be
addressed. It finds that not much can be done with the present level and quality of data
collection; also it points out that most of the discussions are made with traditional
thinking that accidents occur due to errors of human judgment. It recommends that data
collection should be made more relevant and robust while also opining to build up a
technical capacity which shall help policy makers to understand the critical issues and
plan effectively.63
India already has an effective act in place. The motor vehicle act of the Indian parliament,
the proper and uniform implementation of this act, all across the country.
20
1.10) Rationale of the study
What are the factors related to use and non use of helmet?
What have been the experiences of policy makers and implementers in trying to enforce
this legislation?
Search for answers to these questions forms the rationale of this study. It may come up
(A) To study the factors for non compliance of mandatory helmet wearing legislation,
(B) To examine what has been the role of the media in matters related to helmet
legislation Policy.
21
Chapter 2: METHODOLOGY
2.1) Study Design: Both „Quantitative” and „Qualitative research methods. The study had
Thiruvananthapuram.
Kerala.
2.2) Conceptual Framework: The conceptual framework may be explained with the
22
2.3) Cross Sectional Survey
2.3.1) Study Setting: The study setting was Thiruvananthapuram, which is the capital city
from adjoining districts or state, thus there was no clear cut denominator. With feasibility
in mind, the sample size was estimated at 300 motorized two-wheeler drivers.
2.3.3) Sample Selection: Participants were selected from 31 public parking lots in
Thiruvananthapuram City. Every third motorized two wheeler driver coming in to the
parking lot was approached. Participants were thus selected from these parking lots,
which were all across the city. The procedure was continued until the requisite numbers
were achieved.
2.3.4) Data Collection: A pre tested structured interview schedule was used. Also a scale
for „risk perception‟ was a part of the schedule. Data collection was done during the
2.3.5) Data Storage: All data are kept safely with the principal investigator, who shall
bear the sole responsibility for safe keeping and any breach of confidentiality. Transfer of
data was kept to a minimum. Data shall be with the principal investigator for any future
reference.
2.3.6) Data Analysis and Statistical Measures: Data analysis was done during the period
from 15/09/2010 to 14/10/2010. Descriptive analysis was done to look at the sample
characteristics. Bivariate analysis was done to find the relation between the predictor and
outcome variables. I further did multivariate analysis using logistic regression and came
23
up with the final model for my study. All these analyses were done using the computer
2.3.7.1) Need for the scale: This scale was developed by the investigators for this study.
To the best of our knowledge, no similar scale has been developed before.
2.3.7.2) Defining the construct: This is a scale to measure the Risk Perception among two
wheeler drivers, for getting injured/ losing life in the event of an accident, while driving
○ In-depth interviews with eight motorized two wheeler drivers were done.
○ An initial item pool of 15 items was generated, using the findings.
○ This was later tabulated in the form of a scale, using appropriate language.
○ The responses were classified using likert Scaling.
○ This was put up for „Face validation‟ among three experts.
○ This expert group consisted of an epidemiologist, an anthropologist and a
public health physician.
○ The number of items in the scale was brought down to eight on the advice
of this group.
○ Then it was put up for „Content Validation‟ among another group of 6
experts.
○ This group comprised of an epidemiologist, a health policy analyst, two
psychologists, two public health physicians and an anthropologist.
○ According to the advice given, subtle changes were brought in the
language of the statements and the number of items was brought down to
seven.
○ Both Negatively and positively worded sentences were used as items.
○ Translation and Back translation was done in English-Malayalam-English.
○ The sample of this study was used as the development sample for the
scale.
○ Cronbach Coefficient alpha was derived for the internal consistency.
○ Test-retest was done on a development sample of 30.
○ According to the findings, the scale length was optimized to four items.
○ Cronbach alpha value for the scale is 0.74
○ Test-retest kappa value for the scale is 0.77
○ The scoring pattern was decided.
○ These scores were used for further analysis in the study.
24
2.3.7.4) Limitations of the scale: This scale needs further validation and it cannot be
carrying regular passenger, self head injury, others head injury, ever fined.
Dependent Variables:
(A) Helmet wearing status: This was observed by the investigator and noted down
No; in possession but not wearing; wearing but unstrapped; and Yes.
(B) Risk Perception: Risk Perception was gauged using a scale developed for this
purpose. The items were graded from values 1 to 4 and scores were given
score for the four items were added up to give the final score of the scale.
The final score had a possible range from 4 to 16. The scoring pattern
25
within the sample was analyzed to find the median score. The respondents
were then classified into two categories. Those with a median score or below it
scores above the median were categorized as „Good Perception.‟ Those with
median scores were included into „poor perception,‟ as the investigator felt it
Independent Variables:
5. Marital Status: As reported by the respondent. The enquiry was made, based
6. Driving years: Respondents were enquired regarding how long they have been
7. Power of the two-wheeler: The power of the two-wheeler the respondent was
driving at the time of investigation was noted down as per the following three
26
8. Knowledge on Government order: Respondents were asked whether they knew
9. Seen Advertisement: Respondents were enquired whether they had ever come
10. Regular passenger: Respondents were enquired whether they carried any
passenger in the pillion on a daily basis. Responses were noted down as Yes/No.
11. Self Head Injury: Respondents were enquired whether they had ever suffered
from a head injury while riding a two wheeler. Responses were noted as Yes/No.
12. Any Known Head Injury: Respondents were enquired whether they knew of
someone among their friends or relatives who had suffered from head injury
13. Ever Fined: Respondents were enquired whether they had ever been fined by
the police on the grounds of driving a two wheeler without wearing helmet. The
14. Alcohol Consumption: This was self reported. The enquiry was a set of two
questions. First was whether the respondent had ever consumed alcohol. If the
answer was yes, they were asked whether they had consumed alcohol in the last
month. Based on the responses, they were classified into three categories: Non
15. Smoking: This was self reported. The enquiry was a set of two questions.
First was whether the respondent had ever smoked tobacco. If the answer was
yes, they were asked whether they had smoked tobacco in the last month. Based
27
on the responses, they were classified into three categories: Non Smoker; Ex
2.4.1) Content Used: Newspaper reports published in the following two newspapers:
2.4.2) Inclusion and exclusion criterion: All the reports pertaining to helmet legislation
and a few relevant reports pertaining to road safety published during the period from
01/07/2003 to 31/06/202005 and from 01/07/2008 to 31/06/2010 were included. All the
from the archive maintained in their office and noted down. Malayala Manorama had a
complete digital archive, which was used for collecting the reports.
All the data is stored with the principal investigator and may be used for further
2.4.5) Reporting the result: The report is in the form of comments of how the media
reports have been detrimental in policy changes. Also the themes of reporting through
28
2.5) Key Informant Interviews:
2.5.1) Sample selection: The study population consisted of policy makers and
implementers of the helmet law. They were approached at random and whoever agreed
study.
2.5.2) Sample size: Sample size was eight. It consisted of three bureaucrats, two sub
inspectors of the police department, one researcher, one politician and a police officer.
The sample size was limited to eight as the researcher felt saturation in information and
2.5.3) Data collection and storage: Data was collected after receiving consent, using a
English according to his choice. All participants agreed for the interviews to be
digitally recorded. These recordings were later transcribed and translated by the
researcher. In this tabulated form, the data were analyzed. All digital recordings and
transcripts are kept safely with the principal investigator. It shall be completely
2.5.4) Data Analysis: Deductive themes were generated after the interviews, using the
guideline as template. Analysis was taken one step further by doing a stake holder
analysis.
taken into account when developing and/or implementing a policy or program. The
29
related to the policy, position for or against the policy, potential alliances with other
Stakeholder analysis was done on the participants of my study with the help of a
matrix64 and ranked in the order according to their hierarchical importance in policy
making. Theme-wise opinions are reported and given weightage according to their
ranks.
2.5.6) Reporting the result: Results are reported as themes and comments on each
theme. There is also a final comment on the overall state of the policy and finding gaps
in the policy. The report also consist the findings of stakeholder analysis.
2.6) Triangulation: I have tried to triangulate the findings from my various components
and come up with comments in the discussion. I have also attempted to give certain
the interviews regarding helmet use except the loss of time and the inconvenience
of the venue – the parking lots. This was no more that what the subjects would
encounter by way of routine everyday life experiences. Care was also taken to
In Cross Sectional Survey: Name and address of the participant was not enquired.
Consent form was separately filed and not linked to the questionnaire. Interview
30
In Depth interviews: Identity of the interviewee was only known to the principal
investigator. Once consent was taken, further analyses were done only on the basis
2.7.3) Benefits: This study did not have any direct benefit to the participant.
However it has the potential to bring forth policy changes, which may prove
2.7.4) Informed consent processes: Informed consent was taken by the principal
31
CHAPTER-3: RESULTS
Minimum: 4; Maximum: 16; Mean: 11.72; Standard Deviation: 2.908; Median: 12.0
Taking the median as cut-off, risk perception was classified into two categories. Those
with a score equal or less than median value were denoted as „poor perception‟ while
those with a score greater than median value were considered as „good perception‟
32
3.1.3 Sample characteristics:
Table 3.3: Pattern of the socio-economic predictors
Up to class 12 80 51 29 43 37
(31.6) (31.9) (31.2) (30.7) (32.7)
Graduate 134 83 51 84 50
(53) (51.9) (54.8) (60) (44.2)
PG and above 39 26 13 13 26
(15.4) (16.2) (14) (9.3) (23.1)
Occupation Group
Unemployed/ Students 54 31 23 36 18
(21.3) (19.4) (24.7) (25.7) (15.9)
Govt Employee 58 36 22 34 24
(22.9) (22.5) (23.7) (24.3) (21.2)
Private Employee 86 58 28 47 39
(34.0) (36.2) (30.1) (33.6) (34.5)
Professional 22 13 9 9 13
(8.7) (8.1) (9.7) (6.4) (11.5)
Others 33 22 11 14 19
(13.0) (13.8) (11.8) (10) (16.8)
Total 253 160 93 140 113
(100) (100) (100) (100) (100)
Marital Group
Never Married 86 50 36 45 41
(34) (31.2) (38.7) (32.1) (36.3)
Ever Married 167 110 57 95 72
(66) (68.8) (61.3) (67.9) (63.7)
Total 253 160 93 140 113
(100) (100) (100) (100%) (100)
33
Table 3.4: Pattern of the predictors for driving behavior
34
Table 3.5: Pattern of the demographic predictors
Up to 30 104 65 39 58 46
(41.1) (40.6) (41.9) (41.4) (40.7)
30-44 94 67 27 46 48
(37.2) (41.9) (29.05) (32.9) (42.5)
>=45 55 28 27 36 19
(21.7) (17.5) (29.05) (25.7) (16.8)
Total 253 160 93 140 113
(100) (100) (100) (100) (100)
Sex
Female 50 31 19 23 27
(19.8) (19.4) (20.4) (16.4) (23.9)
Male 203 (80.2) 129 74 117 86
(80.6) (79.6) (83.6) (76.1)
Total 253 160 93 140 113
(100) (100) (100) (100) (100)
No 48 36 12 47 1
(19) (22.5) (12.9) (33.6) (0.9)
Yes 205 124 81 93 112
(81) (77.5) (87.1) (66.4) (99.1)
Total 253 160 93 140 113
(100) (100) (100) (100) (100)
Seen
advertisement
No 83 55 28 56 27
(32.8) (34.4) (30.1) (40) (23.9)
Yes 170 105 65 84 86
(67.2) (65.6) (69.9) (60) (76.1)
Total 253 160 93 140 113
(100) (100) (100) (100) (100)
35
Table 3.7: Pattern of the predictors for personal habits
Self head N (%) of N (%) of those N (%) N (%) of those N (%) of those
injury the total „not wearing of those with „poor risk with „good risk
sample helmet‟ „wearing perception perception
helmet‟
36
3.1.4 Reasons cited for observed helmet wearing behavior:
*Cumulative percentage may be more than 100% as the question had multiple responses.
i. Those who have been 'never fined' are 0.5 times likely to 'not wear helmet'.
ii. Those who have not seen any advertisement are 2.12 times likely to have
37
iii. Those who have been 'never fined' are 0.49 times likely to have „poor risk
perception'.
iv. Those having 'poor risk perception' are 4.275 times likely to 'not wear
helmets'.
3.1.7 Inferences:
iii. It is also seen that 'risk perception' has a substantial effect on the 'helmet
3.1.8 Multivariate analysis: Multivariate analysis was done using „binary logistic
regression‟. Variables selected were from those found to have significant relation in
bivariate analysis and few from the researcher‟s discretion. Three models have been
constructed for: „risk perception‟, „helmet wearing‟ and a final model for „helmet
wearing‟ which includes „risk perception‟ as a predictor. „Risk perception‟ was found to
have a significant bearing on „helmet wearing‟ and no confounding effects.
38
Table 3.11: Multivariate model to explain „helmet wearing‟
* „R‟ square value = 0.196; „knowledge on order‟ removed, as OR gets skewed thus
indicating confounding.
39
Table 3.13 Number of reports and distribution
2003- 11 5 16 24 19 43 35 24 59
05
2008- 8 10 18 37 7 44 45 17 62
10
Overall 19 15 34 61 26 87 80 41 121
* TH = The Hindu; MM = Malayala Manorama (Also 5 more reports pertaining to „Policy‟ from the period
between 2005 and 08 were included from MM during analysis.)
3.2.2 Reports on policy: All the „policy reports‟ were arranged chronologically to form a
historical perspective of helmet legislation in the state.
3.2.3 Historical perspective of policy: The document on historical perspective was
analyzed and the following inferences were made:
i. Kerala has been path breaking in several aspects.
- The first road safety authority in the country was set up here in 2005
ii. Efforts are not always sustained.
- Frequent and confusing shifts between soft and strict enforcement
iii. Opposition to the legislation is not based on any scientific findings.
- Mostly organized by political groups with police harassment being the bone of
contention
iv. Lot of political activism was involved with this legislation.
- Usual forms of protests are as mass rallies with political patronage.
v. The high court has been the most pro active stakeholder.
- High court has always takes the initiative to make rulings and send reminders to the
government to take action.
vi. The government implements the legislation for temporary phases.
- Usually they are knee jerk reaction to court orders, which usually withers away with
time and protests.
40
vii. Methods of implementation have always varied.
- There have been instances when lawbreakers were given gifts instead of being fined.
- It was once decided to not nab the offenders but only note down their numbers and
send challans to their addresses
- The latest method is to set up notified spots where helmet checking shall be done.
3.2.4 Other reports on helmets: Initially, they were analyzed and given primary codes.
They were then re-analyzed and given secondary codes. The secondary codes were then
re-coded to form the themes.
3.2.5 Themes derived: The secondary codes along with the final themes are as depicted
below:
Table 3.14 Deriving the themes in content analysis
41
04 Problems of adherence Peoples’ view
Political view
Difficulty to follow rule
Sale of helmets
3.2.6 Distribution of themes over time: The distribution of these themes in the reporting
in the two newspapers across time is as depicted below:
Table 3.15 Distribution of themes in content analysis
TH MM Total TH MM Total
Voice of dissent 10 9 19 7 3 10 29
Statistics: Increasing 6 6 9 3 9 15
Decreasing 9 12 12
Voice of support 10 4 14 2 2 4 18
Problems of adherence 4 9 13 4 4 17
Enforcement methods 5 3 8 7 1 8 16
Awareness building 4 1 5 7 7 12
Problems of enforcement 2 2 4 5 5 9
42
3.2.7 Interpretation of themes:
o Most of the reports have been on „voices of dissent‟ but the trend over time
is downwards.
o Reports showing statistics are certainly taking more print space over time.
o Problems of adherence have been reported well and constantly over time.
o Awareness building and reports on enforcement methods are also being
reported more over time.
43
3.3 In-depth interviews
3.3.1 Stake holder analysis:
3.3.1.1 Matrix used:
3.3.1.3 Result of stakeholder analysis: The results for stake holder analysis are
tabulated below:
44
Rank Post Dept Internal/ Knowledge Stand Interest Alliances Resources Leadership
External
Code
7&8 Sub Traffic Internal Mod Neutral Vested Poor Mod Poor
Insp Police
Rank code: The rank as per the stakeholder analysis. Shows comparative influence in aspects related to policy.
Position and organization: Explains the organization which the stake holder represents and his hierarchical
position in it.
Internal/external: Internal stakeholders work within the organization that is promoting or implementing the
policy; all other stakeholders are external.
Knowledge of policy: the level of accurate knowledge the stakeholder has regarding the policy under analysis.
Position: whether the stakeholder supports, opposes, or is neutral about the policy.
Alliances: Organizations that collaborate to support or oppose the policy. Alliances can make a weak
stakeholder stronger.
Resources: the quantity of resources and his or her ability to mobilize them.
45
3.3.2 Themes derived: Themes were deduced from the guidelines and the questions
asked in the in-depth interviews. They are:
i. Personal opinion
ii. Problem identification
iii. Prioritization
iv. Implementation methods
v. Problems of implementation
vi. Specific recommendations
3.3.3 Theme-wise opinions: Theme wise opinions of the stakeholders were analyzed and
the final interpretations made.
3.3.4 Interpretation: All comments from the interviews were analyzed and weighted
according to the findings of the stakeholder analysis. All these opinions have been
presented according to the themes in a ranked order. Thus the first opinion is expressed
Personal opinion:
Problem identification:
1) Lack of awareness:
„In Kerala, everyone believes that he is competent enough to create awareness‟
2) Lack of civic sense:
„But even in highly civilized society, legislations are necessary‟
3) Lack of adherence is specific to certain places:
„I have served in several places; it is especially tough to implement the law in
Thiruvananthapuram‟
46
4) Fine amount is very low:
„In the current scenario of growing incomes, a fine of Rupees means nothing to
anyone‟
5) Helmets are uncomfortable:
„Even I don‟t wear a helmet as the size of my head is huge and I don‟t get helmets
in the market which fits in comfortably‟
6) Poor policy:
„When smaller states are making it compulsory, there is no justification in the fact
that Kerala with its huge vehicle population does not take road safety issues
seriously‟
7) Negative role played by media:
“Reports in media state that police is busy with „helmet hunting‟; such reports
have a negative impact on the mindsets of the people”
8) Harassment by implementing officials:
“Instead of harassing the two-wheeler riders, implementers should try scientific
methods of implementation”
7) Inconvenient to carry:
“People find it inconvenient to carry around and unsafe to leave it in the vehicle”
8) People do not want to be forced into wearing helmets:
“People ask - it is my head and I shall take care of it, why should the government
force me to?”
Prioritization:
1) Given priority only at certain times like when there is a court order:
“Whenever there is a court order we become more cautious until the matter
settles down”
2) It is a small issue and not top priority:
“There are so many things for the government to do and not just to make people
wear helmets”
3) So many lives are lost, it is certainly a priority:
“Who will take responsibility for all the lives lost in the process?”
47
Implementation methods:
1) Spot checking and noting down registration numbers at non-peak hours:
“We note down the registration numbers of the offenders and send notices to pay
fine to the address”
2) Stop and collect fine on the spot:
“We stop the offenders, collect fines and give receipts on the spot”
3) Noting down registration numbers only during peak hours:
“Only during peak hours we note down registration numbers, otherwise we
collect on the spot”
Problems of implementation:
1) Shortage of manpower:
“We can do it, just give us the staff”
2) Lack of political will:
“Nothing can succeed if the rulers do not show will”
3) Available manpower has several other duties:
“It is not humanly possible to do all the duties given to a traffic policeman”
4) Lack of inter-sectoral co-ordination:
“Police does not want to work with motor vehicles department and vice-versa”
5) People may have medical ailments:
“People sometimes have genuine medical ailments but the law does not exempt
them and we end up antagonizing them”
6) Scientific methods are not followed in implementing the legislation:
“We have so much to learn from other countries who have successfully
implemented but here it‟s either all or none law which is followed”
7) Limited powers given to implementers:
“We don‟t even have powers to pursue an offender racing away, most of the time
we are made to look like a bunch of jokers”
8) Availability of various types of helmets makes it impossible to check standards:
“There are so many designs and forms, even we as implementers are not sure on
which of those adheres to the standards”
48
Specific recommendations
1) Awareness building:
“Only legislation never works, people should be made aware”
2) Inculcate habits of safety from school level:
“Such habits of safety should be thought from home and school; adults always
have the tendency to resist”
3) Inter-sectoral co-ordination:
“Absolutely necessary, but ego hurts”
4) Improve helmet designs:
“Just making the helmets comfortable to wear shall improve the situation”
5) Take stringent measures against law breakers along with disincentives for not wearing
helmets
“It is time to get tough; we have already lost several lives”
6) Media should be more pro-active:
“Especially in Kerala, media has a major role to play”
7) Scientific campaign with soft enforcement:
“Successful campaigns have always started through soft enforcement and
awareness”
8) Prioritize road safety:
“With so many deaths and injuries, nothing else can be a bigger priority”
9) Provide helmets at the time of purchase
10) Find sponsors to provide all two-wheeler riders with standard helmets
“If everyone has helmets, at least some of them will wear”
49
Chapter 4 DISCUSSION AND CONCLUSION
4.1 Discussion
We find that more than 80 percent of the respondents were males while almost 80
percent of the respondents were below 45 years of age. These findings correspond
with the general belief that motorized two-wheelers are mostly used by young
males and it also corresponds with the findings of another independent study done
in Kerala. 41
percent were married. Since motorized two wheeler drivers form a specific group
by themselves, these rates cannot be related with findings in the population. But
the other study from Kerala also had similar findings. Private employees formed
The indicators on driving behavior find that 60 percent have been driving a
motorized two wheeler for more than five years. More than 70 percent of the
motorized two wheelers used have engine power less than 125 cc and almost 60
is that nearly 44 percent of the respondents have been fined for not wearing
50
Nineteen percent of them did not know whether a universal helmet law exists
whereas almost 33 percent have never seen any advertisement in any form of
percent had current tobacco smoking. The rate for alcohol consumption is as
expected but tobacco smoking is less than expected66, which may be due to under-
reporting.
Only 36.8 percent of the participants wore helmets properly. Almost 14 percent
were wearing helmets without fastening the chin-strap. These findings indicate
low levels of proper helmet wearing practices which were as expected and a little
Most common reasons cited for wearing helmets are self protection (by almost 73
percent of the people) and stipulation of law (50.5 percent). Those not wearing
helmets mostly cited reasons such as discomfort (almost 47 percent) and hearing
4.1.1.3 Perception of risk: There were four items in the scale used for risk
51
Item 1: Helmet wearing v/s Head injury Item 2: Helmet wearing v/s distance travelled
Item 3: Helmet wearing v/s Power of vehicle Item 4: Helmet wearing v/s Speed
38%
42%
Poor Perception Poor Perception
Good Perception Good Perception
58%
62%
The median value for this particular sample was taken as cut off and more than 55
percent people had poor risk perception. As there were no studies done earlier on
Both poor risk perception and the behavior of not wearing helmet are strongly
associated with being fined repeatedly. Thus being fined for not wearing helmet
does not make a person wear one nor does it improve their risk perceptions. This
helmet wearing or maybe that the amount collected as fine is not prohibitive
enough.
52
It was also found that those who had not seen any advertisement regarding helmet
wearing were more likely to have poor risk perception. Risk perception is found to
Thus, risk perception is an important determinant for helmet wearing behavior and
has to be taken into consideration while making policies. One reason why not
many factors had significant influence on helmet wearing may be the fact that
4.1.2.1 Number of reports: There have been a total of 121 reports over the four
years analyzed. Over time, the number of reports has increased slightly in the
newspaper. The Malayalam daily also has started reporting more about issues of
policy and less of other reports. But overall, The English language daily has
Though „voice of dissent‟ has been the dominant tone of reporting, it is certainly
reducing. This may be an indicator of a change within the media in the state.
There seems to be more acceptances for the necessity of legislation. Also reports
based on „awareness building‟ and „statistics‟ are more now. This is a positive
development and as experienced in Viet Nam, media has a very effective role to
53
4.1.2.3 A historical perspective:
It points towards a lot of dilly-dallying with regards to the helmet policy. There
has been no sustained political effort and unscientific protests at all times. Only
the high-court has been a savior with court rulings and reminders to the
government from time to time. Helmet policy in the state seems to have been
driven by the central government and the high court, with the state government a
passive player responding to their initiatives and diktats. The policy of exempting
pillion riders from wearing helmets is not based on any scientific findings and
purely in response to protests. It is high time that the policy is to pursue legislation
opinions derived from in-depth interviews. Helmet and its legislation encompass
the efforts of several departments and there is necessity to look into the views of
making, as most of the complaints pertain to poor designs of the helmets. Also
department and several others should be included into fold for the success of the
policy.
54
4.1.3.2 Opinions of the stakeholders:
Almost every stakeholder is of the opinion that helmet wearing is necessary and
consensus among all stakeholders that there is a need to look into the policy is
important.
They have varying opinions on why the policy has not been successful. After
weighing their opinions according to their rank in stakeholder analysis, the most
comes next in the list is also closely related to awareness levels. The feeling that
determines it. Collecting fine as a disciplinary action has to be rethought and also
Uncomfortable helmets and inconvenience to carry are aspects which the helmet
manufacturers have to work out. The World Health Organization has assigned
Stakeholders accept that helmet legislation is an important issue but does not merit
prioritization on its own. They would rather prefer that road safety as an entity be
given priority and this would indeed be the right thing to do. Implementation is a
rather prickly issue and there is no uniform views regarding the implementation
confused the two-wheeler riders are. So the primary thing to do would be to have
55
uniformity across board for which again we need strong inter-sectoral co-
ordination.
„lack of political will‟. These are not problems which cannot be solved. Public
awareness level in the population. Among the other problems cited, inter-sectoral
coordination or rather the lack of it keeps cropping up. Kerala is the first state to
have a road safety authority in our country and one of its agendas is to foster
These points discussed have been re-iterated by the stakeholders also in their
„inculcate safety habits from school level‟ and „inter-sectoral co-ordination‟ in that
enforcement against others who prefer it to be soft. But among the stakeholders
interviewed in this study, the scale tilts towards a strong enforcement calling for
stringent action against law-breakers. Also there is call for the media to play a
more positive and meaningful role. Some specific recommendations suggest either
that helmets be provided along with the vehicle at the time of purchase or to
schemes.
56
4.1.4 Triangulation:
The findings from the three components which are included in triangulation are:
4.1.4.2 Findings of triangulation: These have been arranged under two headings:
„problems‟ and „solutions‟. They have been depicted pictorially using the
58
Fig. 4 Solutions identified by the study
59
4.4 Recommendations and policy implications of the study:
This study basically tried to find the present status of the policy related to helmet
legislation in Kerala. It also intended to find the loopholes and make some suggestions.
With all the above mentioned limitations, it has been partially successful in achieving its
ends. We could identify problems from each component of the study and the solutions too
came from within the study. The final recommendations which this study would like to
● Road safety authority may be made the nodal agency for helmet legislation.
● Foster a strong multi-disciplinary co-ordination network.
● Include all stake-holders and form a policy of implementation.
● Give sustained support- both political and monetary- for the implementation.
● Encourage more research and awareness programs.
● Try to intervene towards improving the risk perception of two-wheeler riders.
● Media should play a positive role in policy making as well as awareness building.
● Try to inculcate habits of safety into school curriculum.
● Try to provide all two-wheeler riders with either free or affordable, good quality
and comfortable helmets.
● Rethink the strategy of collecting fines from people and think of either raising the
fine amount or other modes of disciplinary action.
4.5 Conclusion: This study is to be treated as a beginning towards further research in the
broad field of road safety in general and helmet legislation in particular. More evidence
has to be brought into policy making and several unnecessary deaths avoided. No study
can be perfect and even this study has its limitations. But the finding of this study can
60
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Appendix-I
Informed Consent
Dr. N.S.Vishwanath
MPH 2009, AMCHSS
SCTIMST, Trivandrum
Cell: 9446064738
Email: vishy@sctimst.ac.in
In case you need any clarifications about my credentials or the study you can also contact
Dr. Raman Kutty V, Professor, AMCHSS, SCTIMST, Trivandrum-695011 or, Dr. Anoop
Kumar Thekkuveettil, Member-Secretary of the Institutional Ethical Committee at
SCTIMST, Trivandrum.
The information obtained from you will be kept confidential and will be used only for
research purpose. You are free to with draw from the interview at any point of time. Also
you can refuse to answer any question that you are not comfortable with.
Yes No
If you are not willing to take part thank you for your time.
If you are willing please give your signature/ thumb impression over here.
I am Dr. N.S.Vishwanath, MPH Scholar from the Achuta Menon Centre for Health
Science Studies in Sree Chitra Tirunal Institute for Medical Sciences and
Technology, Trivandrum and am conducting a policy study on ‘Helmet Legislation
and its implications in Kerala’. I would be doing a policy analysis to know why
helmet legislation is a tough law to implement. You are one of the key persons in
policy formulation/ implementation of this legislation and hence selected for this
interview. This is an exploratory study and I am only interested in your opinions
about the various matters concerning the helmet legislation which would help
formulate recommendation to improve the policy.
Dr. N.S.Vishwanath
MPH 2009, AMCHSS,
SCTIMST, Thiruvananthapuram.
Cell: 9446064738
Email: vishy@sctimst.ac.in
In case you need any clarifications about my credentials or the study you can
also contact Dr. Anoop Kumar Thekkuveettil, Member-Secretary of the
Institutional Ethical Committee at SCTIMST, Trivandrum (Contact: 0471-
2520256/257).
Participation in this interview will involve about 30-45 minutes of your time. You
are free to refuse to participate in the interview at anytime during the course of
the interview and free to refuse to answer any question at anytime. You may not
be benefited due to participation in this study except that the findings of the study
may help in general to improve the public health impact of proper implementation
of the Helmet Legislation in the state. The information that you give me will be
treated as strictly confidential and used only for the purpose of research.
If you agree to participate in this interview, I would also request your permission to
record this interview. Details of this interview will be transcribed and used exclusively
for research and your name and that of your department/ institution will not be
identified in the transcriptions that will be used for analysis. Records and transcripts
of the interviews will be kept under safe custody and analyzed by me. After writing
the report at the end of the study, the same will be destroyed.
…………………………………………………………Date:……………….
…………………………………………………………..Date:………………..
Appendix-III
INTERVIEW SCHEDULE
Questions: Responses:
01. AGE
02. SEX A. Female
B. Male
03. What is your educational status? A. Illiterate
B. Below Class 8
C. Class 8 to Class 12
D. Graduate
E. Post Graduate and above
04. What is your Occupation? A. Unemployed
B. Student
C. Government Employee
D. Private Employee
E. Professional
F. Others. Specify: ________
05. What is your Marital Status? A. Single
B. Married
C. Separated/ Divorced
D. Widowed
06. How long have you been driving a
two-wheeler? (In years)
07. How often do you wear a helmet? A. Always or almost always
B. Sometimes
C. Never or almost never
08. Is there a government order requiring
two-wheeler riders to compulsorily A. No
wear helmet? B. Yes
09. Power of the two wheeler of the A. < 75 cc
driver. (To be observed) B. 75cc to 125 cc
C. >= 125cc
10. Helmet Wearing Status (To be A. No
observed) (More than one response B. In possession but not wearing
may be ticked) C. Wearing but unstrapped
D. Yes
10.1 If No (A or B or C), Why? a. Not necessary
b. Police will not catch
c. Hinders my visibility
d. Hinders my hearing
e. Uncomfortable to wear
f. Others. Specify _________.
10.2 If Yes(C or D), Why? a. Self protection
b. Since law requires
c. Due to responsibilities
d. Necessary for getting insurance
e. Advertisements advice it.
f. Others. Specify ____________.
11. Have you seen any advertisements or
commercials on TV or any other media a. No
propagating helmet use? b. Yes
12. Do you carry any regular passengers on
your two-wheeler) e.g. Wife, children, a. No
friends, etc)? b. Yes
13. Have you ever consumed alcohol? a. No
b. Yes
Checklist
Was there any relation between the topic and article? (Yes or No).
I am Dr.N.S.Vishwanath, MPH Scholar from the Achuta Menon Centre for Health
Science Studies in Sree Chitra Tirunal Institute for Medical Sciences and Technology,
Trivandrum. I am conducting a policy study on the ‘Helmet Legislation in Kerala’ as part
of my MPH dissertation. As you are one of the key persons in the policy formulation/
implementation of this legislation, I have approached you for this interview. This is only
an exploratory study and my interest is to know about your opinions about the relevant
matters concerning the Helmet Legislation Policy and recommendation to improve the
policy. More precisely to understand why we do not have an effective Helmet Legislation
Enforcement in the state and two wheeler accidents, especially head injuries remain an
important public health concern.
If you permit me to record the interview, that would be convenient for me to save time
and to ensure all important points from you are duly noted. The recording of your
interview will be kept under safe custody and transcribed without using your identity, but
only an identifying code. Both the record and the transcription of your interview will be
used for research purposes only and at the end of the study the same will be destroyed. If
you are willing to be interviewed but not willing to permit recording of the interview, I
can keep notes of the interview. If so, please sign in the appropriate section.
Thank you
3. What do you think are the key issues with respect to the current policy, that are
good and which need correction? Why do you say so?
4. Opinion about the countrywide enactment of legislation? Which you consider
more effective - state run enforcement or centralized enforcement? Why?
5. Significance of Public Health activists and NGOs? - their functional status in the
state, any strategies to associate them for Helmet legislation?
Political will
Policy support
Resources
A comprehensive programme
Inter sectoral co-ordination
or due to some other reasons? If so, what are they?
I am Dr.N.S.Vishwanath, MPH Scholar from the Achuta Menon Centre for Health
Science Studies in Sree Chitra Tirunal Institute for Medical Sciences and Technology,
Trivandrum. I Am conducting a policy study on the ‘Helmet Legislation in Kerala’ as
part of my MPH dissertation. As you are one of the key persons in the policy
formulation/implementation of this legislation, I have approached you for this interview.
This is only an exploratory study and my interest is to know about your opinions about
the relevant matters concerning the Helmet Legislation Policy and recommendation to
improve the policy. More precisely to understand why we do not have an effective
Helmet Legislation Enforcement in the state and Two wheeler accidents, especially head
injuries remain an important public health concern.
If you permit me to record the interview, that would be convenient for me to save time
and to ensure all important points from you are duly noted. The recording of your
interview will be kept under safe custody and transcribed without using your identity, but
only an identifying code. Both the record and the transcription of your interview will be
used for research purposes only and at the end of the study the same will be destroyed. If
you are willing to be interviewed but not willing to permit recording of the interview, I
can keep notes of the interview. If so, please sign in the appropriate section.
Thank you.
4. What are the major problems faced while implementing the legislation?
7. Most literate state, but people still don’t want to wear helmets and hence the high
Injury rate –about the IEC strategies on awareness among people?
8. How do you liaison with other sectors for the control of this problem?
Political will
Policy support
Resources
A comprehensive programme
Sectoral co-ordination
or due to some other reasons? –What are they?