Helmet Use Among Adolescent Motorcycle and Moped Riders -- Rome, Italy, 1994

In Italy, motor-vehicle crashes are the leading cause of death among persons aged 15-20 years, and motorcycles account for a substantial proportion of traffic-related fatalities: in 1993, of the 6349 traffic-related deaths reported in Italy, 1342 (21.1%) occurred among motorcycle and moped users, and 261 (19.4%) of these deaths were among persons aged 15-20 years. Because of the risks for head injury and death, in 1986 a national law was enacted requiring operators of motorcycles or mopeds to use helmets under specified conditions. To assess compliance with this law and factors associated with helmet use among adolescents in a metropolitan area, in October 1994 the National Institute for Health conducted a survey of a sample of high school students in Rome. This report presents findings of this survey, which indicate that helmet use was low, particularly among moped users and among passengers.

In Italy, motor-powered cycles are classified by engine size. Motorcycles with engines 50-125 cc may be operated by persons aged greater than or equal to 16 years; persons must be aged greater than or equal to 18 years to operate motorcycles with engines greater than 125 cc. For both, drivers' education and a license are required. Mopeds (vehicles with engines less than or equal to 50 cc) -- which are designed for use in urban areas and are smaller than motorcycles -- may be operated by anyone aged greater than or equal to 14 years; neither a license nor drivers' training is required. Carrying passengers on mopeds is prohibited regardless of the age of the driver. A 1986 law mandated helmet use for all moped drivers aged less than 18 years; for those aged greater than or equal to 18 years, helmet use is required only when mopeds are operated outside urban centers. The 1986 law also mandated helmet use by both drivers and passengers of motorcycles, regardless of the operator's age and location of motorcycle use.

The survey was conducted in October 1994 at six public schools located in central Rome, representing the three types of high schools in Italy (classical, scientific, and technical). All students in the first, third, and fifth years (mean ages: 14, 16, and 18 years, respectively) who were present on the day of the survey were asked to complete an anonymous self-administered questionnaire regarding sociodemographic characteristics, motorcycle and/or moped use and use of helmets during the previous year, and attitudes about helmet use.

Of the 1690 students present on the day of the survey, 1673 (99.0%) students (mean age: 16.4 years; range: 13-23 years) completed the questionnaire. More than half (988 {59.1%}) reported having been a passenger on (565 {57.2%}) or driven (423 {42.8%}) either a moped or motorcycle during the previous year. Males and females were equally likely to use motor-powered cycles, although males were more than twice as likely as females to be drivers (34.9% versus 16.4%). Nearly one fourth (23.1%) of respondents reported daily use of at least 1 hour of either motorcycles or mopeds. Most (897 {90.8%}) motor-powered cycle users were moped riders, of whom 396 (44.1%) were drivers and 501 (55.9%) were passengers.

Of the moped and motorcycle users, 494 (50.0%) reported helmet use (sometimes or always wore a helmet when riding). Of those reporting helmet use, more than two thirds (71.2%) reported sometimes using helmets, and 28.8% reported always using helmets. Helmet use was greater among drivers (59.8%) than passengers (42.7%; p less than 0.01) (Table_1) and was greater among motorcycle users than moped users (82.9% versus 48.6%; p less than 0.01). Among those using mopeds and who where aged less than 18 years (i.e., mandated to use helmets), 54.9% reported using helmets sometimes or always; among those aged greater than or equal to 18 years (i.e., required to use helmets only when traveling outside city limits), 24.6% reported using helmets sometimes or always (p less than 0.01).

Helmet use during the most recent trip was reported by 23.2% of all motorcycle and moped users and was more common among those who reported always using a helmet (89.4%) than among those who reported occasional use (23.1%). Among those who reported using helmets sometimes or always during the previous year, 70.6% reported always fastening the chin strap, 19.8% reported doing so sometimes, and 6.9% reported that they never did. Constant correct use of helmets was reported by 17.3% of motorcycle and moped users overall.

Among respondents who reported always using helmets, the most common reasons for use were that helmets provided protection (57.4%) and that they were required by law (31.9%). Among those who reported sometimes or never using helmets, the most frequent reasons for nonuse were that they are uncomfortable (40.9%), not available (20.4%, all passengers), or useless (5.7%).

Among all respondents, 81.8% believed helmets provided protection in crashes, and 65.7% believed use should be compulsory; however, nonusers of motorcycles and mopeds were more likely to favor compulsory use than users (80.0% versus 56.8%, respectively). Most respondents considered motorcycle riding to be dangerous (48.2%) or very dangerous (37.0%).

Of the 423 drivers, 268 (63.2%) reported having been involved in at least one crash. Of these, 53 (19.9%) reported injuries requiring an emergency department visit, and 12 (4.3%) required inpatient admissions.

Reported by: P Baldaccini, MC Biagioli, M Boscolo Nata, M Cassiani, M Cavinato, VA Caporale, M Chironna, A Ciglia, RM Conforti, P Fermani, P Gallo, L Gardenghi, G Giostra, F Giurdanella, F Grippi, P Lopalco, E Lorenzo, E Martini, G Maugeri, F Michieletto, A Monti, PA Napoli, B Niccoli, A Petrucci, M Portera, S Raspanti, G Rimenti, G Ripabelli, A Romano, A Sanguedolce, R Sestili, F Sforza, AR Silvestri, G Silvestri, A Stella, BO Tchangmena, F Terragni, L Trezzi, R Trigilio, D Viviani, Field Epidemiology Training Program; P D'Argenio, A Infuso, T Manfredi-Selvaggi, A Niccolini, G Salamina, S Salmaso, L Sodano, F Taggi, S Viviani, National Institute of Health, Rome, Italy. Div of Tuberculosis Elimination, National Center for HIV, STD, and TB Prevention (proposed); Div of Unintentional Injury Prevention, National Center for Injury Prevention and Control, CDC.

Editorial Note

Editorial Note: Although motorcycles and mopeds are an inexpensive mode of individual transportation, in most countries, they are associated with the greatest risks for transportation-related injuries (1). Per vehicle mile, motorcycle drivers are approximately 20 times more likely than passenger-car occupants to die in a motor-vehicle crash (2). In the United States, head injuries occur in approximately 53% of motorcycle-related deaths (3). Motorcycle helmets are 46%-85% effective in reducing the incidence of severe, serious, and critical head injuries (4) and 29% effective in reducing fatalities (5). In addition, nonhelmeted riders who are injured have been more likely to require ambulance service; be admitted to a hospital; incur higher hospital charges; require neurosurgery, intensive care, rehabilitation, and long-term care; and sustain permanent disabilities (4).

Laws requiring helmets for population subgroups (such as the one applying to moped users in Italy) are substantially less effective than laws requiring universal helmet use (4) and are difficult to enforce. In the United States, helmet laws that apply to population subgroups (i.e., persons aged less than or equal to 18 years) result in helmet use of 42%-59%. In comparison, in states with universal helmet laws, up to 99% of riders use helmets (4,6).

The findings in this report are subject to at least two limitations. First, only six schools were included in the survey, all in the central part of Rome. Although the three types of schools were included in the survey to ensure the representation of students of different academic achievement levels and different socioeconomic strata, participants probably were not representative of all students in Rome. Second, because self-reported data often overestimate use of safety devices, actual helmet use probably was less than that reported (7).

To improve the enforcement of laws related to mopeds, license plates for mopeds are now mandatory. Although this requirement should decrease the number of mopeds carrying more than one person, underenforcement of age-specific helmet use is expected to remain a problem. Results of this survey have been provided to the Ministry of Transport in support of extending helmet use to all moped users in Italy. In addition, the results were used to prepare a health-education leaflet, produced jointly by the ministries of health and education, on the importance of helmet use that was distributed to high school students throughout Italy.

Because helmet use can reduce fatalities associated with head injuries among motorcycle riders and can reduce the severity of nonfatal head injuries, helmet use among motorcycle and moped riders should be encouraged worldwide. In the United States, universal helmet laws (i.e., requiring all riders to wear a helmet) have been the most effective method of increasing helmet use.

References

1. Trinca GW, Johnston IR, Campbell BJ, et al. Reducing traffic injury -- a global challenge. Melbourne, Australia: AH Massina & Co., Royal Australasian College of Surgeons, 1988.

2. National Highway Traffic Safety Administration. Traffic safety facts 1994 -- motorcycles. Washington, DC: U.S. Department of Transportation, National Highway Traffic Safety Administration, National Center for Statistics and Analysis, 1995.

3. Sosin DS, Sacks JJ, Holmgreen P. Head injury-associated deaths from motorcycle crashes: relationship to helmet-use laws. JAMA 1992;264:2395-9.

4. US Government Accounting Office. Motorcycle helmet laws save lives and reduce costs to society. Washington, DC: Government Accounting Office, 1991; report no. GAO/RECD-91-170.

5. Wilson DC. The effectiveness of motorcycle helmets in preventing fatalities. Washington, DC: US Department of Transportation, National Highway Traffic Safety Administration, 1989; publication no. DOT-HS-807-416.

6. CDC. Head injuries associated with motorcycle use -- Wisconsin, 1991. MMWR 1994;43: 423,429-31.

7. Hunter WW, Stewart JR, Rodgman EA. Characteristics of seat belt users and non users in a state with a mandatory belt use law. Health Educ Res 1990;5:161-73.

TABLE 1. Helmet use * among high school students, by vehicle ridden -- Rome, Italy, 1994
===========================================================================================
                        Moped +              Motorcycles &           Total @
                      -----------            -----------           -----------
                      Used helmet            Used helmet           Used helmet
User charac-   No.    -----------     No.    -----------    No.    -----------
 teristics    riders  No.    (%)     riders  No.    (%)    riders  No.    (%)
-------------------------------------------------------------------------------------------
User/Age **
 Drivers
  <18 years    251    191    (76.1)     8     8    (100.0)    261    201    (77.0)
 >=18 years    139 ++  38    (27.3)    17    13    ( 76.5)    156     51    (32.7)
  Total        396    231    (58.3)    25    21    ( 84.0)    423    253    (59.8)

 Passengers
  <18 years    276    124    (44.9)    35    28    ( 80.0)    396    195    (49.2)
 >=18 years    125 ++  27    (21.6)    15    12    ( 80.0)    163     44    (27.0)
  Total        406    159    (39.2)    51    42    ( 82.4)    565    241    (42.7)

 Overall
  <18 years    527    315    (59.8)    43    36    ( 83.7)    657    296    (45.1)
 >=18 years    264 ++  65    (24.6)    32    26    ( 81.3)    319     95    (29.8)
  Total        802    390    (48.6)    76    63    ( 82.9)    988    494    (50.0)

Used helmet
 during most
 recent trip   802    162    (20.2)    76    49    ( 64.5)    988    229    (23.2)

Used helmet
 correctly &&  802    109    (13.6)    76    43    ( 56.6)    988    171    (17.3)
-------------------------------------------------------------------------------------------
*  Reported always or sometimes wearing a helmet.
+  Engine size <=50 cc.
&  Engine size >50 cc.
@  Includes 110 passengers who did not know engine size.
** Numbers may not add to total because of missing user/age data.
++ Not required by law to wear a helmet.
&& Always wears helmet and always attaches chin strap.
===========================================================================================

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