Road traffic crashes (RTCs) claim 1.35 million lives and cause 20–50 million injuries resulting in disability each year, particularly in low- and middle-income countries (WHO, 2018). In Uganda, road traffic injuries are a fast increasing public health problem and, currently, the tenth leading cause of disability and death (IHME, 2019) (Figure 1). Although RTIs affect all road users, some groups are disproportionately affected. Motorcyclists are more likely to get fatally injured than other motor vehicle users (NHTSA, 2007). For instance, 28% of global road traffic deaths are mong motorcyclists (WHO, 2018), and they are the second-most vulnerable road user group, after pedestrians, in low-income countries (Grimm and Treibich, 2010).
The decline of well-organized public transport systems in sub-Saharan has led to rapid growth in the use of commercial motorcycles as the preferred public transport mode with a concomitant increase in motorcycle crashes (Kumar, 2011; Olvera et al., 2012). Therefore, this report highlights the magnitude, analyses the determinants and inequalities of commercial motorcyclist injuries in Uganda, and outline a health needs assessment plan to address the needs of commercial motorcyclists to reduce injuries and death from crashes.
The burden of motorcycle taxi riders’ injuries in Uganda
Motorcycle taxis, locally known as boda boda, at an annual growth rate of 58.7 percent are the fastest growing fleet on Uganda’s roads (UNECE and UNECA, 2018). This growth has been driven by their popularity among Ugandans because of their convenience, flexibility and easy manoeuvrability through heavy traffic (Wanume et al., 2019). In parallel with this rapid growth, motorcycles have become the leading contributor to RTCs than any other vehicle type (Roehler et al., 2013), and led to a surge in motorcycle-related injuries and deaths (Vaca et al., 2020).
Motorcyclists are at high risk of injury and death from RTCs (NHTSA, 2007). In Uganda, the risk of a motorcyclist getting seriously injured or dying in a crash is 3.6 times and 5.5 times that of a car driver, respectively (Annual Crime and Road Safety Report, 2019). This increased risk of injury and death could be due to reduced protection against other vehicles, ground, and roadside objects, motorcycles being smaller, less visible to motor vehicle drives and less stable on the road (Freeman et al., 2012).
According to the Annual Crime and Road Safety reports, the proportion of motorcycle involved in RTCs increased by 7.5% from 2010 to 2019 and, correspondingly, the constitution of motorcyclists’ injuries and fatalities have increased by 7.4% (17.9% in 2009 to 25.3% in 2019) and 13.2% (14.2% in 2009 to 27.4% in 2019), respectively. These increments are the highest compared to all other road user groups (Figure 2). These police reports’ data are, however, like in other low-income countries, an underestimation of the true burden of RTIs (Bhalla et al., 2016; Heydari et al., 2019). For example, Zafar et al. (2018) reported that in 2014, motorcycle injuries constituted 53% of RTCs versus official 24.5% reported in that year (Annual Crime and Road Safety Report, 2015).
Motorcycle road traffic injuries (RTIs) also impose an enormous economic burden (Wanume et al., 2019). They are the largest contributors of trauma victims (41%) to Mulago National Referral Hospital (MNRH); and with an average of US$ 369 to treat a single victim, motorcycle injuries account for 4.2% of MNRH’s annual budget and 62.5% of the MNRH directorate of surgery budget (Kigera, Nguku and Naddumba, 2010). It is estimated that the total economic burden of motorcycle RTCs, due to lost productivity resulting from severe injuries and death and repairs, is US$ 3.6 million—0.02% of Uganda’s GDP (Sebaggala et al., 2015).
Determinants of motorcycle injuries
Motorcycle RTIs are determined by interacting multiple factors at different levels. Figure 2 shows the Dahlgren and Whitehead’s conceptual model, which provides a framework to understand the determinants of health at the individual, social and community networks, living and working conditions, and wider socioeconomic and environmental levels (Dahlgren and Whitehead, 1991). Table 1 summarises some risk factors for motorcyclist RTIs at each ecological level.
The risk factors at the levels described in Figure 3 and Table 1 interact in complex ways within (intra) and across (inter) levels to result in motorcyclists RTIs. Being a young male (18–25 years) is associated with risky driving behaviours (Chang and Yeh, 2007; Olumide and Owoaje, 2015), which increase injury risk—an intra-level interaction at the individual level.
Inter-level risk factor interactions are common. For instance, unhealthy family relationships engender negative emotions, which increase injury risk by lowering risk perception, distorting rational judgement and increasing risky driving behaviours (Atombo et al., 2017). Frustration from competition with other motorcyclists and motor vehicle taxis (Siya et al., 2019) may increase injury risk via the pathways reported by Hu, Xie and Li (2013).
The conditions in which commercial motorcyclists operate including poorly constructed and maintained roads, car-centric road designs, and high traffic volume and mix increases risk of motorcyclist RTIs (Balikuddembe et al., 2017).
Socioeconomic, cultural and environmental factors influence motorcyclists’ RTI risk. Low socioeconomic status (SES) is associated with high motorcycle RTI risk (Zambon and Hasselberg, 2006). High unemployment lead increasing numbers of youths to commercial motorcycling (Galukande et al., 2009), thus increasing the number of people exposed to RTI risk.
Economic stress related to poor income increases motorcyclists’ injury risk (Kitara and Karlsson, 2020). Strong cultural and religious beliefs in fate/destiny are, in some settings, positively associated with risky road use and low practise of protective behaviours, such as helmet use, while in other settings a negative association occurs (Heydari et al., 2019). Low enforcement of traffic rules has downstream effects on motorcyclists’ driving behaviours to increase RTI risk (Vaca et al., 2020). Inadequate capacity for road safety research and practice (Heydari et al., 2019) may indirectly increase risk of RTIs due to lack of proper motorcyclist RTI surveillance, thus, inadequate local evidence to inform prevention strategies. Furthermore, a lack of political will and inadequate funding to address RTCs, and lack of a strong lead agency increase RTI risk (UNECE and UNECA, 2018).
No studies investigating the specific environmental determinants of motorcycle injuries in Uganda were found, but environmental factors like weather could play a role (Lankarani et al., 2013).
Inequities in motorcycle injuries
Although RTIs affect all motorcyclists, some sections of this population have a disproportionate risk. Some of this unequal distribution of risk, health inequity, is due to the wider social and economic factors that no individual motorcyclist may have control over. As the Health Equity Analysis matrix in Table 2 illustrates, some groups of motorcyclists accumulate more RTI risk factors than others.
The health inequity analysis is drawn from Kitara and Karlsson (2020), Siya et al. (2019), Tumwesigye et al. (2016), and Vaca et al. (2020) who investigated boda boda injuries and associated factors in Uganda. Generally, these studies focused on behavioural factors without considering the distal factors that could influence the motorcyclists’ behaviours; they did not explore inequities or inequalities in injury risk thus limiting their findings’ relevance to health inequities in motorcycle RTIs. Major findings across the studies showed increased injury risk associated with being young, substance use, low riding experience, low income, intense competition for customers and long working hours. A shortcoming of Tumwesigye et al. (2016) is that respondents were motorcyclists admitted to public hospitals which limits generalisability of findings since some injured riders do not go to hospital and others may opt for private medical care. Only Kitara and Karlsson (2020) explored a distal determinant, economic stress, and this was significantly associated with increased injury risk among commercial motorcyclists. The strength of these studies is that they are specific to Uganda’s context. However, more research is needed to explore the distal and proximate determinants and inequities in motorcycle injuries.
Due to the paucity of relevant studies, reference is made to Zambon and Hasselberg (2006) who investigated socioeconomic differences in motorcycle injuries in Sweden, but findings may differ from the Ugandan motorcyclist population because of different country contexts. The association between low SES and high injury risk has, however, been found in other road users (RoSPA, 2012), and as such, reference is made to other studies whose populations were not motorcyclists, on the assumption that similar inequities could occur among motorcyclists.
Health needs assessment plan for commercial motorcycle injuries
Aim: To identify commercial motorcyclists’ needs to reduce severe road traffic injuries.
Using this approach, the commercial motorcyclist population would be profiled in terms of the prevalence or incidence of injuries and how it affects their health functioning, assess the current injury prevention measures, and their effectiveness and cost-effectiveness (Table 3). Relevant information sources to guide this approach include hospital injury/trauma admissions records, current mitigation measures from police reports, and effective preventive interventions and their cost-effectiveness from literature reviews.
This approach would enable gather opinions on the needs and what has to be done from RTI prevention experts (for normative needs) in academic institutions and traffic police departments, commercial motorcyclists (felt and expressed need), people in communities where commercial motorcyclists operate, surgeons/doctors who treat injured motorcyclists, politicians who influence policy and media.
This approach would make use of literature reviews and results of health needs assessments in commercial motorcyclist populations in other low-income countries whose contexts are similar to Uganda’s.
For a successful HNA, different stakeholders have to be involved and engaged in the most effective ways to increase chances of success. These, however, differ in their influence—power to facilitate or impede the HNA’s objective(s), and importance—priority given to meeting the interests and needs of each stakeholder (DFID, 2003).
Commercial motorcyclists, in this case have very high importance, because the HNA is designed to meet their needs/interests, but may have little influence to have their needs met. One way to engage motorcyclists would be through a large cross-sectional survey, asking them for opinions on their (felt and/or expressed) needs and how they think these can be met. This approach, in addition to being cheap, would allow engagement with many motorcyclists, and if respondents are randomly selected, views could be generalized to the whole motorcyclists’ population. Other engagement approaches include focus group discussions with motorcyclists’ leaders and one-on-one interviews.
Surgeons/doctors are essential in determining the outcome of injured motorcyclists admitted to their care, but may have low influence in preventing the RTIs on the road. Roads engineers/designers greatly influence the safety of motorcyclists by designing roads that plan for vulnerable users or not but low on importance. These groups could be engaged through focus group discussions/interviews to gain their views and learn their perceptions of the HNA and its proposed interventions.
Motorcycles are the fastest growing fleet in Uganda (UNECE and UNECA, 2018) and have become the most dominant mode of public transport in Uganda. As motorcycle taxi use has grown, so has the number of road traffic injuries. Today motorcycle taxi injuries are a major public health problem in Uganda, with enormous health, social and economic costs. The factors, as explored in the report using the Dahlgren and Whitehead model, are widely varying, occur at different levels and interact.
From this report, some gaps have been identified. It is very likely that the true burden of motorcycle injuries is higher than officially reported due to poor road crash data management and poor monitoring and evaluation of road safety (UNECE and UNECA, 2018), underscoring the urgent need for high-quality research on the nature, magnitude, and patterns of motorcycle injuries to inform prevention and treatment policy (Hsia et al., 2010). Studies cited largely focused on behavioural determinants of RTIs, so there’s a need for studies exploring the role of more distal factors influencing motorcycle injuries. It is possible that inequities identified in injury among other road users (RoSPA, 2012) could be present among motorcycle taxi riders and thus a need for research in this area which is almost non-existent.