Policy Study of the Helmet Legislation in

Kerala and its Implications.

Dr. N.S.Vishwanath

Dissertation submitted in partial fulfillment of the requirements

for the award of the degree of
Master of Public Health

Achutha Menon Centre for Health Science Studies

Sree Chitra Tirunal Institute for Medical Sciences and Technology

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.

Thank You All.

 Certificate

I hereby certify that the work embodied in this dissertation

entitled “Policy study of the Helmet Legislation in Kerala and its
Implications” is a bona fide record of original research work
undertaken by Dr. N.S.Vishwanath, in partial fulfillment of the
requirements for the award of the degree of „Master of Public Health‟
under my guidance and supervision.

Prof (Dr). Raman Kutty, MD, MPH, MPhil;

Achutha Menon Centre for Health Science Studies,
Sree Chitra Tirunal Institute for Medical Sciences and Technology,
Thiruvananthapuram, Kerala.
October 2010.
 Declaration

I hereby declare that the work embodied in this

dissertation entitled “Policy Study of the Helmet Legislation in
Kerala and its Implications” is the result of original research and
has not been submitted for any degree in any other university or
institution.

Dr. N.S.Vishwanath, MPH-2009,

Achutha Menon Centre for Health Science Studies,
Sree Chitra Tirunal Institute for Medical Sciences and Technology,
Thiruvananthapuram, Kerala.
October 2010.
 TABLE OF CONTENTS
LIST OF TABLES
LIST OF FIGURES
ABSTRACT
CHAPTERS Page No.

Chapter 1 INTRODUCTION AND REVIEW OF LITERATURE

1.1 Introduction and background……………………………………………………………… 1
1.2 Injury:
1.2.1 Problem Statement…………………………………………………....................... 3
1.2.2 The way forward………………………………………………………………….. 4
1.3 Road Traffic Injuries:
1.3.1 Problem statement………………………………………………………………... 4
1.3.2 The Indian Context……………………………………………………………….. 5
1.3.3 The Kerala context………………………………………………………………... 6
1.3.4 The way forward………………………………………………………………….. 6
1.4 Motorized two wheelers:
1.4.1 Problem statement………………………………………………………………... 7
1.4.2 What does research say?......................................................................................... 7
1.4.3 Head injuries……………………………………………………………………… 8
1.5 Helmets:
1.5.1 Mechanism of protection…………………………………………………………. 9
1.5.2 Effectiveness of helmets……………………………………………………….….. 9
1.5.3 Helmets and policy………………………………………………………………..10
1.6 Helmet Laws:
1.6.1 How it helps………………………………………………………………..…..….10
1.6.2 How law should be enforced……………………………………………………..11
1.6.3 Experiences from around the world………………………………………….….11
 1.6.4 The Indian context…………………………………………………………..……12
1.6.5 The Kerala Context………………………………………………………...……..13
1.6.6 Behavior of helmet wearing………………………………………………..…….14
1.6.7 What leads to disobedience?..................................................................................14
1.7 Risk Perception:
1.7.1 Attitudes and Behavior………………………………………………………...…15
1.7.2 Risk Perception and Behavior………………………………………………...…15
1.7.3 Modeling the relation between risk, attitude and behavior…………………....16
1.7.4 Risk Perception in policy making………………………………………………..16
1.8 Media and its role……………………………………………………………………….......17
1.9 Policy and its formulation:
1.9.1 Law as a tool………………………………………………………………………17
1.9.2 Lessons learnt: The US case study………………………………………………18
1.9.3 Lobbies and Policies………………………………………………………….…...18
1.9.4 Individual rights versus Public health policy……………………………….…..19
1.9.5 The way forward…………………………………………………………….……20
1.9.6 The Indian Context…………………………………………………………….…20
1.10 Rationale of Study……………………………………………………………………..…..21
1.11 Objectives of the study………………………………………………………………...…..21

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:

Table 3.1: Helmet wearing pattern……………………………………………………………….32

Table 3.2: Risk Perception Pattern……………………………………………………………….32
Table 3.3: Pattern of the socio-economic predictors…………………………………………….33
Table 3.4: Pattern of the predictors for driving behavior……………………………………..….34
Table 3.5: Pattern of the demographic predictors………………………………………………..35
Table 3.6: Pattern of the predictors for knowledge……………………………………………....35
Table 3.7: Pattern of the predictors for personal habits……………………………………….…36
Table 3.8: Pattern of the predictors for injury……………………………………………………36
Table 3.9: Bivariate analysis of ‘helmet wearing’ v/s ‘risk perception’…………………………37
Table 3.10: Multivariate model to explain ‘risk perception’………………………………….…38
Table 3.11: Multivariate model to explain ‘helmet wearing’…………………………………....39
Table 3.12: Final multivariate model for ‘helmet wearing’…………………………………...…39
Table 3.13 Number of reports and distribution………………………………………………..…40
Table 3.14 Deriving the themes in content analysis…………………………………………......41
Table 3.15 Distribution of themes in content analysis………………………………………..….42
Table 3.16: Results of the stakeholder analysis………………………………………………….45

LIST OF FIGURES:

Fig.1: Conceptual framework of the study………………………………………………………22

Fig.2: Item-wise response to the scale for risk perception……………………………………….52
Fig.3: Problems identified in the policy cycle………………………………………………...…58
Fig.4: Solutions identified by the study………………………………………………………….59
 Abstract

“Policy Study of the helmet legislation in Kerala and its implications.”

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.

Analysis of in-depth interviews helped in identified factors such as ‘Lack of awareness’,

‘shortage of manpower’ and ‘lack of political will’ among other factors having a negative impact
on the policy.

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

1.1) Introduction and background:

Injury is defined as “damage or harm caused to the structure or function of the body

caused by an outside agent or force, which may be physical or chemical.” It is estimated

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. .

An accident is a specific, unexpected, unusual and unintended external action which

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

such events and the injuries thus arising. .

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

personal modes of transport which is also affordable. Motorized two-wheeler vehicles

such as motorbike, scooter or mopeds perfectly fit the bill. .

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

the riders wear safety helmets.

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

such interventions is also very crucial. .

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

1.2.1 Problem Statement:

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.

1.2.2 The way forward:

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

should be substantiated through efficacy and effectiveness research. Finally, we should

disseminate the research which encourages the communities and policy makers to adopt

evidence based programmes.1

1.3) Road Traffic Injuries

1.3.1 Problem statement:

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

economically active age groups.

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

distinction of heading this list.

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

global road traffic deaths.3

1.3.2 The Indian Context:

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

cardio-vascular diseases in terms of public health burden and impact. Absence of

substantial scientific research has adversely affected our understanding on how to

overcome this situation.4

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

public health issue to be recognized as a preventable cause of loss of healthy life.5

Among the few available articles, one calls for increased participation of health

professionals towards rectifying the situation through health promotion and increased

research in this field (Mohan D, 2004).6

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

1.3.3 The Kerala context:

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

bearing in mind that most cases go unreported.

1.3.4 The way forward:

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

action for road safety.” 10

6
1.4) Motorized two wheelers

1.4.1 Problem statement:

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

of deaths amongst two-wheelers at 21,872.11, 12

1.4.2 What does research say?

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

analyze the situation.

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

tends to be most for motorcycles followed by scooters and then mopeds.14

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

had to continue making clinical visits for medical or rehabilitation issues.15

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

varied from Rupees 17,000 to 35,000.17

1.4.3 Head Injuries:

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

brain injuries such as concussion, contusion and hemorrhage.18

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

amount of energy transferred to the injured person in a crash. If the rider is

unprotected, the amount of energy transfer will be much higher and injuries severe.

8
1.5) Helmets

1.5.1 Mechanism of protection:

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

impact to a larger area.19

1.5.2 Effectiveness of helmets:

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

non helmeted rider is 0.61.21

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

reduce the cost of health care.19

1.5.3 Helmets and policy:

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

1.6) Helmet Laws

1.6.1 How it helps:

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

decrease in mortality due to head injuries among occupants of motorized two-wheelers

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

accounted for before any legislation.30

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

scientific approach and improved police performance.31 For the enforcement to be

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

conditions. This has been its biggest bane.32

1.6.3 Experiences from around the world:

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

percent reduction in death rates.36

1.6.4 The Indian context:

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

motorized two-wheelers constitute the most vulnerable group.

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

throughout the country but is to be implemented by each state through notifications. It is

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

respect the law.37

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,

death rates decreased by 30 to 40 percent, head injuries reduced by 20 to 30 percent while

the severity and neurological complications came down by almost 40 percent.

Furthermore, duration of hospitalization and medical costs also dropped by up to 30

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

help in alleviating these factors.40

1.6.5 The Kerala Context:

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

percent of them were found wearing helmet.41

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

towards proper implementation of the legislation.44

1.6.7 What leads to disobedience?

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

defiance of law continues. Justification of defying the law is a persistent question in

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

bearing on helmet wearing practice.47

14
1.7) Risk Perception

1.7.1 Attitudes and Behavior:

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

expressed in cognitive, affective and behavioral responses‟. Whereas attitudes have a

strong relation with the behavior, attitudes are also influenced by the risk perception. The

type A behavior pattern (TABP), characterized by impatience, time urgency, and

hostility, was originally developed in relation to coronary heart disease. It has also been

found to have a strong proportional relation with risky driving.48, 49

1.7.2 Risk Perception and Behavior:

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

beliefs were more motivated to seek information about cardiovascular diseases as

compared to those with low efficacy beliefs.50

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

Kreps-Porteus model, wherein changes in behavior with factors such as insurance

coverage may also be explained.51

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

agencies and may lead to policies that affect the safety.

1.7.4 Risk Perception in policy making:

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

remains a phenomenon in search of an explanation.52

The cultural theory of risk perception as conceptualized by Douglas and Vildavsky,

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

population around expressed concerns. Highlighting quality control of helmets as a key

issue, the media have identified a potential ongoing role in monitoring the state‟s

initiative.54

1.9) Policy and its formulation

1.9.1 Law as a tool:

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

policy, as it has been found to be effective.55, 56

1.9.2 Lessons learnt: The US case study.

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

health debate. Despite overwhelming epidemiological evidence that motorcycle helmet

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

1.9.3 Lobbies and Policies:

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

to act towards putting a stop to this losses.58

1.9.4 Individual rights versus Public health policy:

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

compared to associated positive and negative consequences.59 Thus before formulating

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

address all the concerns.

An interesting case looking into individual rights versus the public health is the case of

Jacobson versus Massachusetts fought in the Supreme Court of US in 1905. Reverend

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

health, there are constitutional limits to public health powers.60

1.9.5 The way forward:

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

1.9.6 The Indian Context:

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,

passed in 1988 is a comprehensive document. It is time to bring up policies which assure

the proper and uniform implementation of this act, all across the country.

20
1.10) Rationale of the study

In Kerala, certain questions still remain unanswered. They are:

What are the factors related to use and non use of helmet?

Does Risk Perception play a role in their behavior?

What has been the role of media regarding this legislation?

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

with some interesting findings leading to further research in this field.

1.11) Objectives of the study

(A) To study the factors for non compliance of mandatory helmet wearing legislation,

with particular focus on the Risk Perception among motorcyclists.

(B) To examine what has been the role of the media in matters related to helmet

legislation Policy.

(C) To identify factors preventing the proper implementation of this legislation.

21
 Chapter 2: METHODOLOGY

2.1) Study Design: Both „Quantitative” and „Qualitative research methods. The study had

three components as follows:

Component 1: Cross sectional survey of two wheeler drivers in

Thiruvananthapuram.

Component 2: Content analysis of two widely circulated newspapers published

from Thiruvananthapuram, one in Malayalam and the other in English.

Component 3: In-depth interviews of policy makers and policy implementers in

Kerala.

2.2) Conceptual Framework: The conceptual framework may be explained with the

help of the following illustration:

Fig.1: Conceptual framework of the study.

22
2.3) Cross Sectional Survey

2.3.1) Study Setting: The study setting was Thiruvananthapuram, which is the capital city

of Kerala state, India.

2.3.2) Sample Size: Motorized two-wheeler drivers in Thiruvananthapuram may also be

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

period from 15/06/2010 to 14/09/2010.

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

software „SPSS version 17‟.

2.3.7) Scale for „Risk Perception‟:

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

without wearing a safety helmet.

2.3.7.3) Development of scale: This process of scale development was as follows:

○ 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

generalized until tested among various communities.

2.3.8) Variables used:

2.3.8.1) Dependent variables: (A) Helmet Wearing Status

(B) Risk Perception

2.3.8.2) Independent variables:

Demographic variables: Age, sex, marital status.

Socio-economic variables: Education status, occupation.

Variables related to driving: Driving years, power of two-wheeler,

carrying regular passenger, self head injury, others head injury, ever fined.

Variables related to awareness: Knowledge on government order,

ever seen advertisement.

Variables related to personal habits: Alcohol consumption, smoking.

2.3.9) Operational variables:

Dependent Variables:

(A) Helmet wearing status: This was observed by the investigator and noted down

as among the following four categories:

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

according to the wording of the question (negatively or positively). Total

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

were categorized as having „Poor Perception‟ whereas those having overall

scores above the median were categorized as „Good Perception.‟ Those with

median scores were included into „poor perception,‟ as the investigator felt it

apt since majority of the respondents did not wear helmet.

Independent Variables:

1. Age: Age in completed years, as reported by the participant.

2. Sex: Male or female, as observed by the investigator.

3. Education Status: As reported by the respondent. The education status was

enquired as among the following groups: Illiterate; below class 8; class 8 to

class 12; graduate; and post graduate and above.

4. Occupation: As reported by the respondent. The response was enquired using

the following groups: Unemployed; student; government employee; private

employee; professional; and others.

5. Marital Status: As reported by the respondent. The enquiry was made, based

on the following groups: Single; married; separated/ divorced; and widowed.

6. Driving years: Respondents were enquired regarding how long they have been

driving any type of two-wheeler, in completed years.

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

categories: < 75 cc; 75cc to 125 cc; and >= 125cc.

26
8. Knowledge on Government order: Respondents were asked whether they knew

about the existent government order making it compulsory to wear helmets

while driving two-wheelers. The response was noted as Yes/No.

9. Seen Advertisement: Respondents were enquired whether they had ever come

across any advertisement in any form of media advising helmet wearing.

Responses were noted down as Yes/No.

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

while riding a two wheeler. The responses were noted as Yes/No.

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

responses were noted as Yes/No.

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

Drinker; Ex Drinker; and Current Drinker

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

Smoker; and Current Smoker

2.4) Content Analysis

2.4.1) Content Used: Newspaper reports published in the following two newspapers:

The Hindu (English daily – Thiruvananthapuram edition)

Malayala Manorama (Malayalam daily – Thiruvananthapuram Edition)

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

other reports were excluded.

2.4.3) Procedural flowchart: The process followed is as follows:

○ All the collected reports were read and re-read thoroughly.

○ They were coded, checked, re-coded and re-checked.
○ The coding was done with the help of a Checklist.
○ Then the codes were analyzed and classified into themes.
○ The reports were chronologically arranged to see their affects and effects
on policy.
2.4.4) Data collection and storage: All reports from The Hindu were manually browsed

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

analysis in the future.

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

time and between the newspapers are commented upon.

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

to be interviewed was included. Everyone approached agreed to participate in the

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

no new facts forthcoming.

2.5.3) Data collection and storage: Data was collected after receiving consent, using a

pre designed guideline. The respondent was interviewed either in Malayalam or

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

destroyed within one year of submission of the study.

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.

2.5.5) Stakeholder Analysis: Stakeholder analysis is a process of systematically

gathering and analyzing qualitative information to determine whose interests should be

taken into account when developing and/or implementing a policy or program. The

analysis includes such stakeholder characteristics as knowledge of the policy, interests

29
 related to the policy, position for or against the policy, potential alliances with other

stakeholders, and ability to affect the policy process.64

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

suggestions on policy improvement.

2.7) Ethical Considerations:

2.7.1) Risks to the participants: There were no risks involved in participating in

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

keep the inconvenience to a minimum by reducing the questionnaire to the

shortest possible length.

2.7.2) Privacy and confidentiality:

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

schedules were only identified by the serial number.

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

of the characteristics of the interviewee.

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

beneficial to public health at large. The subjects approached in the cross-sectional

survey were given a brochure road safety irrespective of their consent to

participate in the study.

2.7.4) Informed consent processes: Informed consent was taken by the principal

investigator right before administering the interview schedule.

Clearance was obtained from the institutional ethics committee before

commencement of the study.

31
 CHAPTER-3: RESULTS

3.1 Cross sectional survey

3.1.1 Helmet wearing behavior in the sample:

Table 3.1: Helmet wearing pattern

Status: Numbers Percentage

No Helmet 82 32.4
In Possession but not wearing 43 17.0
Wearing but Unstrapped 35 13.8
Wearing Helmet 93 36.8
Total: 253 100
* Wearing an unstrapped helmet is considered as „not wearing helmet‟.

3.1.2 Risk perception in the sample:

The Scoring Pattern within the Scale is as follows:

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‟

Table 3.2: Risk Perception Pattern

Category Numbers Percentage

Poor Perception 140 55.3

Good Perception 113 44.7

Total 253 100

32
3.1.3 Sample characteristics:
Table 3.3: Pattern of the socio-economic predictors

Education: N (%) of N (%) of N (%) N (%) of N (%) of those

the total those „not of those those with with „good
sample wearing „wearing „poor risk risk
helmet‟ helmet‟ perception perception

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)

Total 253 160 93 140 113

(100) (100) (100) (100) (100)

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

Driving N (%) of N (%) of N (%) N (%) of those N (%) of those

years the total those „not of those with „poor risk with „good risk
sample wearing „wearing perception perception
helmet‟ helmet‟

1-5 yrs 101 57 44 55 46

(39.9) (35.6) (47.3) (39.3) (40.7)
6-10 yrs 77 57 20 46 31
(30.4) (35.6) (21.5) (32.9) (27.4)
>=11 yrs 75 46 29 39 36
(29.6) (28.8) (31.2) (27.8) (21.9)
Total 253 160 93 140 113
(100) (100) (100) (100) (100)
Power of
Engine
< 125 cc 179 115 64 101 78
(70.8) (71.9) (68.8) (72.1) (69)
>= 125cc 74 45 29 39 35
(29.2) (28.1) (31.2) (27.9) (31)
Total 253 160 93 140 113
(100) (100) (100) (100) (100)
Regular
passenger
No 147 94 53 84 63
(58.1) (58.8) (57) (60) (55.7)
Yes 106 66 40 56 50
(41.9) (41.2) (43) (40) (44.3)
Total 253 160 93 140 113
(100) (100) (100) (100) (100)
Ever fined
No 142 80 62 68 74
(56.1) (50) (66.7) (48.6) (65.5)
Yes 111 80 31 72 39
(43.9) (50) (33.3) (51.4) (34.5)
Total 253 160 93 140 113
(100) (100) (100) (100) (100)

34
 Table 3.5: Pattern of the demographic predictors

Age Group N (%) of N (%) of N (%) N (%) of those N (%) of those

(in years) the total those „not of those with „poor risk with „good risk
sample wearing „wearing perception perception
helmet‟ helmet‟

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)

Table 3.6: Pattern of the predictors for knowledge

Govt. order N (%) of N (%) of N (%) N (%) of those N (%) of those

the total those „not of those with „poor with „good
sample wearing „wearing risk risk
helmet‟ helmet‟ perception perception

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

Alcohol N (%) of N (%) of N (%) N (%) of those N (%) of those

Consumption the total those „not of those with „poor risk with „good
sample wearing „wearing perception risk perception
helmet‟ helmet‟

Non-drinker 163 97 66 85(60.7) 78

(64.4) (60.6) (71) (69)
Ex-drinker 36 24 12 23(16.4) 13
(14.2) (15) (12.9) (11.5)
Current drinker 54 39 15 32(22.9) 22
(21.3) (24.4) (16.1) (19.5)
Total 253 160 93 140(100) 113
(100) (100%) (100) (100)
Smoking
Non-smoker 183 111 72 96 (68.6) 87
(72.3) (69.4) (77.4) (77)
Ex-smoker 14 10 4 8 (5.7) 6
(5.5) (6.2) (4.3) (7.8)
Current smoker 56 39 17 36 (25.7) 20
(22.1) (24.4) (18.3) (15.2)
Total 253 160 93 140 (100) 113
(100) (100) (100) (100)

Table 3.8: Pattern of the predictors for injury

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‟

No 240 151 89 128 112

(94.9) (94.4) (95.7) (91.4) (99.1)
Yes 13 9 4 12 1
(5.1) (5.6) (4.3) (8.6) (0.9)
Total 253 160 93 140 113
(100) (100) (100) (100) (100)
Others head
injury
No 155 103 52 86 69
(61.3) (64.4) (55.9) (61.4) (61.1)
Yes 98 57 41 54 44
(38.7) (35.6) (44.1) (38.6) (38.9)
Total 253 160 93 140 113
(100) (100) (100) (100) (100)

36
3.1.4 Reasons cited for observed helmet wearing behavior:

For wearing helmets For not wearing helmets

1) Self Protection: 73.1% Uncomfortable: 46.9%

2) Law Stipulates: 50.5% Hearing difficulty: 21.3%

3) Responsibilities: 3.2% Hampered visibility: 19.4%

4)Advertisements: 3.2% Police won‟t nab: 11.9%

5) For insurance: 2.2% Not necessary: 8.8%

6) Others (dust): 4.3% Others: 38.1%

*Cumulative percentage may be more than 100% as the question had multiple responses.

3.1.5 Risk perception as a predictor for helmet wearing:

Table 3.9: Bivariate analysis of „helmet wearing‟ v/s „risk perception‟

Status Not Wearing Wearing OR 95% CI

Score (%) (%) (for not wearing)

Poor Perception 109 (77.9) 27 (22.1) 4.275 (2.480 to 7.368)

Good Perception 51 (45.1) 62 (54.9) 1.00

Total 160 (63.2) 93 (36.8)

* Percentages mentioned are „row percentages‟

3.1.6 Significant findings from bivariate analysis:

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

'poor risk perception'.

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:

i. Collecting fines neither seems to prompt people to wear helmets nor

improves the 'risk perception'.

ii. Advertisements seem to improve „risk perception'.

iii. It is also seen that 'risk perception' has a substantial effect on the 'helmet

wearing behavior‟ of the two-wheeler drivers.

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.

Table 3.10: Multivariate model to explain „risk perception‟

Variables: Unadjusted OR (95% CI) Adjusted OR (95% CI)

Sex (Female : Male) 0.626 (0.336 – 1.166) 1.495 (0.775 – 2.885)

Seen advertisement (No : Yes) 2.123 (1.226 – 3.676) 2.086 (1.188 – 3.662)
Ever fined (No : Yes) 0.498 (0.299 – 0.829) 0.565 (0.332 – 0.961)

* „R‟ square value = 0.077

38
 Table 3.11: Multivariate model to explain „helmet wearing‟

Variables: Unadjusted OR (95% CI) Adjusted OR (95% CI)

Sex (Female : Male) 0.936 (0.494 – 1.772) 0.595 (0.286 – 1.239)

Driving years(<=5 yrs : > 5 yrs) 0.616 (0.366 – 1.037) 0.570 (0.326 – 0.998)
Knowledge on order (No :Yes) 1.960 (0.963 – 3.989) 1.872 (0.892 – 3.928)
Ever fined (No :Yes) 0.500 (0.294 – 0.850) 0.498 (0.284 – 0.873)
Alcohol consumption(Never: Ever) 0.630 (0.364 – 1.090) 0.611 (0.335 – 1.114)

* „R‟ square value = 0.085

Table 3.12: Final multivariate model for „helmet wearing‟

Variables: Unadjusted OR (95% CI) Adjusted OR (95% CI)

Sex (Female : Male) 0.936 (0.494 – 1.772) 0.553 (0.258 – 1.183)

Driving years(<=5 yrs : >5 yrs) 0.616 (0.366 – 1.037) 0.566 (0.317– 1.011)
Ever fined (No : Yes) 0.500 (0.294 – 0.850) 0.558 (0.312 – 0.997)
Alcohol consumption(Never:Ever) 0.630 (0.364 – 1.090) 0.617 (0.328 – 1.161)
Risk perception(poor : good) 4.275 (2.480 to 7.368) 4.101 (2.339 – 7.192)

* „R‟ square value = 0.196; „knowledge on order‟ removed, as OR gets skewed thus
indicating confounding.

3.2 Content analysis

3.2.1 Number of reports: All the reports collected were classified into two categories:
i) Reports pertaining to policy decisions: Policy reports.
ii) All other reports pertaining to helmet and its legislation: Other reports.
The year-wise and newspaper-wise break-up of these reports is as depicted below:

39
 Table 3.13 Number of reports and distribution

Policy reports Other reports All reports

Year TH MM Total TH MM Total TH MM Total

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

Serial No. Final Themes Secondary codes

01 Voice of dissent Peoples’ view

Voice of protest
Policy maker’s view
Protest rally
Political view
Dodging / Coping
Critique

02 Voice of support Peoples’ view

Policy maker’s view
Implementer’s view
Judiciary’s view
Researcher’s view
Support rally

03 Problems of enforcement Sale of helmet

Implementer’s view
Two wheeler preponderance
Road density
Enforcement woes

41
04 Problems of adherence Peoples’ view
Political view
Difficulty to follow rule
Sale of helmets

05 Enforcement methods How enforced

Ideas to improve
Innovative design

06 Awareness building Awareness rally

Researchers’ view
Articles on awareness

07 Statistics (increasing or Statistics showing increasing trends

decreasing trends)
Statistics showing decreasing trends

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

Theme (Ranked) 2003 to 2005 2008 to 2010 Overall

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

* TH = The Hindu; MM = Malayala Manorama

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.

3.2.8 Overall interpretation:

o The total number of reports pertaining to helmet policy has remained
constant.
o The vernacular has started shifting towards more reports related to policy
decisions.
o The themes or the content of the reports have certainly shifted though.
o The shift has been positive and there are more reports in support of the
need to wear helmets of late.
o This is a significant change especially in the vernacular newspaper.
o Any policy decision is immediately followed by a battery of reports mostly
themed on enforcement methods and problems of adherence.
o Reports on voices of dissent have been detrimental in decisions especially
the one exempting pillion riders from wearing helmet.
o There has been a consistent effort by the English language newspaper to
spread awareness by reporting scientific findings and statistics showing the
benefits of helmets.

43
3.3 In-depth interviews
3.3.1 Stake holder analysis:
3.3.1.1 Matrix used:

3.3.1.2 Aspects of policy making analyzed: The various aspects of policy

making which was used in the gridded matrix for each stakeholder were:
i. Law making
ii. Law implementation
iii. Passing orders
iv. Influence on public
v. Ability to marshal resources
vi. Ability to form alliances

3.3.1.3 Result of stakeholder analysis: The results for stake holder analysis are
tabulated below:

Table 3.16: Results of the stakeholder analysis

44
Rank Post Dept Internal/ Knowledge Stand Interest Alliances Resources Leadership
External
Code

1 Head Road Internal Poor Supporter Vested Good Good Good

Safety
Auth.
2 Secy MVD Internal Good Supporter Vested Moderate Good Good

3 Circle Traffic Internal Good Moderate Vested Poor Good Good

Insp Police Supporter

4 Deputy MVD Internal Good Neutral Vested Moderate Mod Mod

Secy

5 Ex- Opposition External Good Opponent Vested Moderate Poor Good

Minister

6 Head Research External Good Moderate Not Moderate Poor Poor

Organizn Opponent Vested

7&8 Sub Traffic Internal Mod Neutral Vested Poor Mod Poor
Insp Police

Explanation of the column headings are as follows:

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.

Interest: The stake holder‟s interest in 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

by most and higher ranked stakeholders.

Personal opinion:

1) Helmet wearing is absolutely necessary:

„After all it saves lives and there is nothing more precious than a human life‟
2) Helmet is protective but not always:
„People should not get the false impression that is protects from accidents or it
protects all parts of the body‟

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

4.1.1 Cross-sectional survey

4.1.1.1 Sample characteristics:

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

Up to 70 percent of the participants had studied up to graduation or above and 66

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 mostly represented group at 34 percent, followed by Government employees

who formed almost 30 percent of the respondents. 41

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

percent do not carry passengers in pillion on a regular basis. An interesting finding

is that nearly 44 percent of the respondents have been fined for not wearing

helmet, at least once.

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

media, suggesting the need to wear helmets.

It was found that 21 percent had current consumption of alcohol whereas 22

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.

4.1.1.2 Helmet wearing behavior:

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

more than the proportion reported in another independent study in Kerala.41

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

difficulty (more than 21 percent) among others.

4.1.1.3 Perception of risk: There were four items in the scale used for risk

perception. The item-wise division of responses among participants has been

depicted through the figures below:

51
 Item 1: Helmet wearing v/s Head injury Item 2: Helmet wearing v/s distance travelled

47% Poor Perception 46% Poor Perception

53% Good Perception 54% Good Perception

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%

Fig.2 Item-wise response to the scale for risk perception

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

this aspect, there are no results to compare these findings with.47

4.1.1.4 Factors influencing outcome variables:

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

may be because of the ineffectiveness of „collecting fines‟, as a tool to improve

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

positively affect the helmet wearing behavior of motorized two-wheeler drivers.

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

„motorized two wheeler drivers‟ as a group are very homogeneous.

4.1.2 Content analysis:

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

English language newspaper while it has reduced a bit in the Malayalam

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

nearly twice as many reports as the Malayalam daily.

4.1.2.2 Themes of reports: There is a perceivable change in the tone of reporting.

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

play in the proper implementation of policy.54

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

in a sustained manner thus leading to many lives being saved.

4.1.3 In-depth interviews:

4.1.3.1 Stakeholder analysis:

The stakeholder analysis was detrimental in giving weightage to the various

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

other stakeholders too. Helmet manufacturers also should be included in policy

making, as most of the complaints pertain to poor designs of the helmets. Also

public health activists, physicians, non-governmental organizations, education

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

the legislation must be properly implemented. This is a good beginning as getting

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

important reason is derived as „lack of awareness‟. Lack of civic sense which

comes next in the list is also closely related to awareness levels. The feeling that

disobedience is region or area-specific needs further research to find out what

determines it. Collecting fine as a disciplinary action has to be rethought and also

the amount is to be debated as the present amount is not prohibitive enough.

Uncomfortable helmets and inconvenience to carry are aspects which the helmet

manufacturers have to work out. The World Health Organization has assigned

region specific designs depending on the climate.19 This has to be incorporated

into manufacturing and made available in the market.

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

methods amongst the stakeholders. If stakeholders themselves are confused about

what is the present mechanism of implementation it is understandable how

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.

Major problems of implementation are mentioned as „shortage of manpower‟ and

„lack of political will‟. These are not problems which cannot be solved. Public

health professionals have a major role especially with regards to increasing

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

strong multi-disciplinary action.

These points discussed have been re-iterated by the stakeholders also in their

recommendations. But the top ranked recommendations are „awareness building‟,

„inculcate safety habits from school level‟ and „inter-sectoral co-ordination‟ in that

order. There is also ambiguity in recommendations with some wanting strong

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

provide all motorized two-wheeler riders with helmets through sponsored

schemes.

56
4.1.4 Triangulation:

4.1.4.1 Findings from each study component:

The findings from the three components which are included in triangulation are:

(a) Cross-sectional survey:

● Collecting fines are not helpful in improving risk

perception.
● Collecting fines are not helpful in improving helmet
wearing practices.
● Advertisements are helpful in improving risk perception.
● Better risk perception is helpful in improving helmet
wearing practices.

(b) Content analysis:

● Most of the reports have been on „voice of dissent‟.

● Newspapers are more supportive of the legislation now.
● Newspaper reports have had an effect on policy decisions.
● The policy with regards to helmet legislation has not been
constantly pursued by the government.
● The judiciary has had a major role up to now with regards
to helmet legislation.

(c) In-depth interviews:

● Awareness level has to be increased among two-wheeler

riders.
● Lack of manpower has to be dealt with.
● Ambiguity among stakeholders‟ versions of implementation
methods used at present.
● Need and lack of inter-sectoral co-ordination raised across
the board.
57
 ● Fine amount is not prohibitive enough.
● Provide all with helmets.
● Design more comfortable and hassle-free helmets.

4.1.4.2 Findings of triangulation: These have been arranged under two headings:

„problems‟ and „solutions‟. They have been depicted pictorially using the

conceptual framework of the whole study.

Fig. 3: Problems identified in the policy cycle

58
 Fig. 4 Solutions identified by the study

4.2 Strengths of the study:

● It is unique in trying to incorporate both quantitative and qualitative research

methodologies.
● It has come up with a scale to gauge „Risk perception‟.
● Instead of concentrating on one group, it has tried to include the views of several
stakeholders.
● It has come with policy recommendations.

4.3 Limitations of the study:

● Causality cannot be proved and scale needs further validation.

● Only two-newspapers were included for content analysis.
● Several stakeholders could not be included for in-depth interviews due to limited
time.

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

make are as follows:

● 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

certainly help in taking a step towards fostering a robust policy.

60
 References

1) National Center for Injury Prevention and Control. CDC Injury Research Agenda,
2009–2018. Atlanta, GA: US Department of Health and Human Services, Centers for
Disease Control and Prevention; 2009. Available at: http://www.cdc.gov/ncipc.
2) Gururaj G. Injuries in India: A national perspective. NCMH Background Papers-
Burden of Disease in India 2005; 325-347.
3) World Health Organization. Global status report on road safety: time for action.
Geneva: WHO; 2009. Available at:
http://www.who.int/violence_injury_prevention/road_safety_status/2009.
4) Soori H, Royanian M, Zali AR, Movahedinejad A. Road Traffic Injuries in Iran:
The Role of Interventions Implemented by Traffic Police. Traffic Injury Prevention
2009; 10(4): 375 – 378.
5) First Global Ministerial Conference on Road Safety: Time for Action. Moscow
Declaration. Moscow; 2009.
6) Gururaj G. Road Traffic Injury Prevention in India. Publication No. 56. Bangalore:
NIMHANS; 2006.
7) Garg N, Hyder AA. Road traffic injuries in India: a review of the literature. Scand J
Public Health 2006; 34: 100–109.
8) Mohan D. Road traffic deaths and injuries in India: time for action. Natl Med J India
2004; 17(2): 63–66.
9) Sethi D, Zwi A. Traffic accidents another disaster? Eur J Public Health 1999; 9(1):
65-67
10) Kerala Police records. Available at: http://www.keralapolice.org/" \n _parent.
Accessed on 15/01/10.
11) National Institute for Mental Health and Neuro Sciences. Two wheeler safety.
Bangalore: NIMHANS; 2006.
12) National Crime Records Bureau. Accidental deaths and suicides in India. Ministry of
Home Affairs, New Delhi, Government of India, 2007.
13) Jha N, Srinivasa DK, Roy G, Jagdish S. Epidemiological study of road traffic
accident cases: A study from South India. Indian J Community Med 2004; 29(1): 20-24.
14) Salatka M, Arzemanian S, Kraus JF, Anderson CL. Fatal and severe injury: scooter
and moped crashes in California, 1985. Am J Public Health 1990; 80(9): 1122–1124.

15) Hotz GA, Cohn SM, Mishkin D, Castelblanco A, Li P, Popkin C et al. Outcome of
Motorcycle Riders at One Year Post-Injury. Traffic Inj Prev 2004; 5(1): 87-89.
16) Gururaj G, Suryanarayana SP. Burden and Impact of Injuries. Results of Population
based survey. Proceedings of the VII World Conference on Injury Prevention and
Control. Vienna; 2004: 275-76.
17) Aeron TA, Jacobs GD, Sexton B, Gururaj G, Rahman F. The Involvement and
Impact of Road Crashes on the Poor: Bangladesh and India, Case Studies. Transport
Research Laboratory, PPRO10, 2004.
18) Jha N. Injury Pattern among Road Traffic Accident Cases: A Study from South India.
Indian J Community Med 2003; 2(28): 85-90.
19) World Health Organization. Helmets: a road safety manual for decision-makers and
practitioners. Geneva: WHO; 2006.
20) Lee HY, Chen YH, Chiu WT, Hwang JS, Wang JD. Quality-adjusted life-years and
helmet use among motorcyclists sustaining head injuries. Am J Public Health 2010;
100(1): 165-70.
21) Norvell DC, Cummings P. Association of helmet use with death in motorcycle
crashes: a matched-pair cohort study. Am J Epidemiol 2002; 156(5): 483-7.
22) Hung DV, Stevenson MR, Ivers RQ. Motorcycle Helmets in Vietnam: Ownership,
Quality, Purchase Price, and Affordability. Traffic Inj Prev 2008; 9(2): 135-143.
23) La TG, Van BE, Bertazzoni G, Ricciardi W. Head injury resulting from scooter
accidents in Rome: differences before and after implementing a universal helmet law.
Eur J Public Health 2007; 17(6): 607-11.
24) Ferrando J, Plasència A, Oros M, Borrell C, Kraus JF. Impact of a helmet law on two
wheel motor vehicle crash mortality in a southern European urban area. Inj Prev 2000;
6(3): 184-8.
25) Tim R, Sass S, Zimmerman PR. Motorcycle Helmet Laws and Motorcyclist
Fatalities. Journal of Regulatory Economics 2000; 18(3): 195-215.
26) Chiu WT, Kuo CY, Hung CC, Chen M. The effect of the Taiwan motorcycle helmet
use law on head injuries. Am J Public Health 2000; 90(5): 793-6.

27) Auman KM, Kufera JA, Ballesteros MF, Smialek JE, Dischinger PC. Autopsy study
of motorcyclist fatalities: the effect of the 1992 Maryland motorcycle helmet use law. Am
J Public Health 2002; 92(8): 1352-5.
28) Muller A. Evaluation of the costs and benefits of motorcycle helmet laws. Am J
Public Health 1980; 70(6): 586-92.
29) Hyder AA, Waters H, Phillips T, Rehwinkel J. Exploring the economics of
motorcycle helmet laws--implications for low and middle-income countries. Asia Pac J
Public Health 2007; 19(2): 16-22.
30) Pervin A, Passmore J, Sidik M, McKinley T, Nguyen TH, Nguyen PN. Viet Nam's
mandatory motorcycle helmet law and its impact on children. Bull World Health Organ
2009; 87(5): 369-73.
31) Laycock, G. New challenges for law enforcement. European Journal on Criminal
Policy and Research 2004; 10: 39-53.
32) Chipman ML. Hats off (or not?) to helmet legislation. CMAJ 2002; 166(5): 602.
33) Homer J, French M. Motorcycle helmet laws in the United States from 1990 to 2005:
politics and public health. Am J Public Health 2009; 99(3): 415-23.
34) Watson GS, Zador PL, Wilks A. Helmet use, helmet use laws, and motorcyclist
fatalities. Am J Public Health 1981; 71(3): 297-300.
35) Branas CC, Knudson MM. Helmet laws and motorcycle rider death rates. Accid Anal
Prev 2001; 33(5): 641-8.
36) Houston DJ, Richardson LE Jr. Motorcycle safety and the repeal of universal helmet
laws. Am J Public Health 2007; 97(11): 2063-9.
37) Robertson LS. Educating and Persuading Individuals In: Causes, Control Strategies
and Public Policy. Mag Camb Univ Med Soc 1993; 91-115
38) Channabasavanna SM, Gururaj G. Chronic Psychosocial Sequelae from Head
Injuries- extent, Nature and Impact. Paper presented at the WHO-CAMHADD
International Conference on Prevention, Understanding and Management of Head
Injuries, Bangalore 1994.
39) Channabasavanna SM, Gururaj G. Head Injuries and Helmets: Implications for
Policies in Developing Countries. Journal of Police Research and Development 1994;
19-24.
40) Khan I, Khan A, Aziz F, Islam M, Shafqat S. Factors associated with helmet use
among motorcycle users in Karachi, Pakistan. Acad Emerg Med 2008; 15(4): 384-7.
41) Jayadevan S, Jayakumary M, Divakaran B, Haran JC. Determinants of safety helmet
use among motorcyclists in Kerala, India. J Inj Violence Res 2010; 2(1): 49-54.
42) Bianco A, Trani F, Santoro G, Angelillo IF. Adolescents' attitudes and behaviour
towards motorcycle helmet use in Italy. Eur J Pediatr 2005; 164(4): 207-11.
43) Oginni FO, Ugboko VI, Adewole RA. Knowledge, Attitude, and Practice of Nigerian
Commercial Motorcyclists in the Use of Crash Helmet and other Safety Measures. Traffic
Inj Prev 2007; 8(2): 137-141.
44) Li G, Li L, Cai Q. Motorcycle Helmet Use in Southern China: An Observational
Study. Traffic Inj Prev 2008; 9(2): 125-128.
45) Kelley AB. Motorcycles and public apathy. Am J Public Health 1976; 66(5):475-6.
46) Jones P. Introduction: Law and Disobedience. Res Publica 2004; 10: 319-336.
47) Zamani AF, Niknami S, Mohammadi E, Montazeri A, Ghofranipour F, Ahmadi F et
al. Motorcyclists' reactions to safety helmet law: a qualitative study. BMC Public Health
2009; 20:393.
48) Iversen H, Rundmo T. Attitudes towards traffic safety, driving behaviour and
accident involvement among the Norwegian public. Ergonomics 2004; 47(5): 555- 572
49) Nabi H, Consoli SM, Chastang JF, Chiron M, Lafont S, Lagarde E. Type A behavior
pattern, risky driving behaviors, and serious road traffic accidents: a prospective study of
the GAZEL cohort. Am J Epidemiol 2005; 161(9): 864-70.
50) Dionne G, Fluet C, Desjardins D. Predicted risk perception and risk-taking
behaviour: the case of impaired driving. J Risk Uncertain 2007; 35:237–264.
51) Cohen, M. Risk Perception, Risk Attitude and Decision: a Rank-Dependent
Approach. CES Working Paper; 2008.
52) Sjoberg L. Factors in risk perception. Risk Anal 2000; 20(1): 1-11.
53) Gustafson PE. Gender differences in risk perception: theoretical and methodological
perspectives. Risk Anal 1998; 18(6): 805-11.
54) Hill PS, Ngo AD, Khuong TA, Dao HL, Hoang HT, Trinh HT et al. Mandatory
helmet legislation and the print media in Viet Nam. Accid Anal Prev 2009; 41(4):789-97.
55) Moulton AD, Mercer SL, Popovic T, Briss PA, Goodman RA, Thombley ML et al.
The scientific basis for law as a public health tool. Am J Public Health 2009; 99(1): 17-
24.
56) French MT, Gumus G, Homer JF. Public policies and motorcycle safety. J Health
Econ 2009; 28(4): 831-8.
57) Jones MM, Bayer R. Paternalism and its discontents: motorcycle helmet laws,
libertarian values, and public health. Am J Public Health 2007; 97(2):208-17.
58) Baker SP. On lobbies, liberty, and the public good. Am J Public Health 1980;
70(6):573-5.
59) Perkins RJ. Perspective on the public good. Am J Public Health 1981; 71(3):294-5.
60) Parmet WE, Goodman RA, Farber A. Individual rights versus the public's health--100
years after Jacobson v. Massachusetts. N Engl J Med 2005; 352(7): 652-4.
61) Birt CA, Gunning-Schepers L, Hayes A, Joyce L. How should public health policy be
developed? A case study in European public health. J Public Health Med 1997; 19(3):
262-7.
62) Passmore JW, Nguyen LH, Nguyen NP, Olive JM. The formulation and
implementation of a national helmet law: a case study from Viet Nam. Bull World Health
Organ 2010; 88(10): 783-7.
63) Dandona R. Making road safety a public health concern for policy-makers in India.
Natl Med J India 2006; 19(3): 126-33.
64) Schmeer, K. Stakeholder Analysis Guidelines: In Policy Toolkit for Strengthening
Healthcare Reform. New York: World Bank; 2000.
65) WHO website. Available at:
http://www.searo.who.int/en/Section1174/Section2469/Section2481.htm. Accessed on:
24/08/2010.
 Appendix-I

Informed Consent

I am Dr. N.S.Vishwanath, Masters in Public Health student from AMCHSS, SCTIMST,

Trivandrum. As part of my curriculum, I am conducting a policy study on “Helmet
Legislation and its implications in Kerala”, under the guidance of Prof (Dr.) Raman
Kutty V. I would like to ask you some questions regarding helmet wearing. There is no
direct benefit for you from the study but public health as a whole may benefit.

This study is being undertaken as part of my dissertation work on Master of Public

Health. I will be the Principal Investigator of the study and my guide is Dr.V.Raman
Kutty. If you need any further clarifications on this matter, you are free to contact me at
the following address:

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.

Are you willing to take part in the study?

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.

Signature of the investigator:

Time:
Date:
Place:
 Appendix-II

Informed consent for Key Informant Interviews

Serial 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 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.

This study is being undertaken as part of my dissertation work on Master of

Public Health. I will be the Principal Investigator of the study. If you need any
further clarifications on this matter, you are free to contact me at the following
address:

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.

Willing to record the interview Yes No

If No, are you still willing to be interviewed? Yes No

Signature of the informant:

…………………………………………………………Date:……………….

Signature of the Interviewer:

…………………………………………………………..Date:………………..
 Appendix-III

INTERVIEW SCHEDULE

Serial Number: _____________Date: _______________Location: __________________

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

13.1. If yes, have you consumed in the last a) No

one month? b) Yes
14. Have you ever smoked? a. No
b. Yes

14.1. If yes, have you smoked in the last one a) No

month? b) Yes
15. Have you ever suffered from head injury a) No
while driving motorized two-wheeler? b) Yes
16. Has anyone in your close circle of friends
and relatives ever suffered from head injury a) No
while driving motorized two-wheeler? b) Yes
17. Have you ever been fined by the police a) No
for not wearing helmet? b) Yes
 Appendix-IV

SCALE FOR RISK PERCEPTION

Item Strongly Strongly

Response Disagree Disagree Agree Agree
1. Helmet wearing prevents
head injuries in case of two
wheeler accidents.
2. Helmets are not necessary for
riding short distances.
3. Helmets are not necessary
while riding two-wheelers
which are less powerful.
4. Helmets are not necessary
while driving at slower speed.
 Appendix-V

Checklist

 When was it reported?

 What was the tone? Supportive or critical of the Policy.

 What prompted the article?

 What is the main topic?

 Did it advocate helmet use?

 What were the suggestions of the article?

 Was there any relation between the topic and article? (Yes or No).

 What types of references were used in the article?

(Academicians, foundation, professional foundation for health, professions,

scholarly journal, enforcement officials, policy makers, bureaucrats, etc.)

 What was the content of the subsequent article?

 Did it have an impact?

 Appendix-VI

Interview guidelines for policy makers and bureaucrats.

Thank you for the permission.

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

1. What is your personal opinion?

 About the protection provided by helmet
 About the necessity of the legislation
 Why there is a cyclic trend in law enforcement

2. What is the role of your department in Helmet Legislation enforcement control?

 How do you prioritize this issue?
 What is the approximate annual loss to society?
 What are the current enforcement measures?
 What are other possible options and about its implementation?

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?

1. Helmets have been found to have a huge beneficial impact on both

morbidity as well as mortality arising out of two wheeler accidents- still
implementing the legislation remains a big challenge- What do you think are
the major reasons? Is it due to lack of

 Political will
 Policy support
 Resources
 A comprehensive programme
 Inter sectoral co-ordination
or due to some other reasons? If so, what are they?

7. Specific recommendations for improving the situation.

Thank you for your great support and valid information.

 Appendix-VII

Interview Guidelines for Policy Implementers.

Thank you for the permission

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.

1. What is your personal opinion?

 About the protection provided by helmet
 About the necessity of the legislation
 Why there is a cyclic trend in law enforcement

2. About the policy of the department in Helmet Legislation Enforcement.

 Does the dept have any prioritized actions?
 What are the methods of Implementation?
 What is done with the fine collected?

3. What is the volume of two wheeler drivers fined?

4. What are the major problems faced while implementing the legislation?

5. What are the limitations towards proper implementation?

6. Training of constables for proper risk assessment is proved better for risk
reduction and cost reduction- what are your thoughts on this?

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?

9. Is it due to the lack of

 Political will
 Policy support
 Resources
 A comprehensive programme
 Sectoral co-ordination
or due to some other reasons? –What are they?

10. Specific recommendations for improving the situation.

Thank you for your great support and valid information.