This study is one among a few qualitative studies that attempt to explore the reactions of motorcyclists to the safety helmet law in Tehran, Iran. Results from the in-depth interviews and focus-group discussions helped to delineate the following themes: (1) circumventing or dodging police officers
; (2) simulating helmet wearing behaviors
; (3) accepting the probability of receiving a ticket;
(4) taking advantage of police neglect and carelessness
; and (5) using a cheap or convenient helmet
. These results reveal risky reactions to the mandatory helmet law among the participating motorcyclists. Indeed, research on safety helmet laws shows that such laws do not necessarily lead to lower traffic road injuries [12
Findings of this study suggest that the reported reactions to the helmet law could be the consequences of a system that operates haphazardly to enforce this law. In other words, the system has failed to consistently penalize those who deviate from this law. Motorcyclists in this study revealed that even when a violator of the helmet law is caught it does not necessarily mean that he will be cited for the violation. A study in northeast Thailand revealed that proper enforcement of the helmet law increased its compliance among motorcyclists, although wearing a helmet did not significantly reduced fatalities among the injured motorcyclists [28
]. A study from Indonesia showed that motorcyclists did not wear their helmet when police officers were not present [29
]. In two mid-sized cities in China, 75% of the riders reported they would wear a helmet not to prevent head injuries but to "cope with the police officers" [3
]. The same study also reported higher rates of helmet use by the motorcyclists during the hours of the weekdays when police officers were more likely to be present [3
Other system-level factors which provoked participants' reactions to the helmet law were "cost", "inconvenience", and the "uncomfortable fit of the helmet." As shown in this study, some motorcyclists use non-standard safety helmets and/or use it improperly to compensate for its high cost and inconvenient fit. Previous studies report that the non-standard helmet and an improper use of safety helmet provides limited protection during a collision [28
]. Despite this fact, the use of non-standard helmets is common among motorcyclists in various countries [17
]. For example, in provincial areas of China, 34% of the riders did not use a helmet at all, and among those who did wear a helmet, 33.7% did not buckle its straps properly [3
]. Following an introduction of the mandatory helmet law in California, about 10% of motorcyclists used a non-standard helmet, and some purchased these less protective helmets unknowingly [30
]. Other studies have cited lack of ventilation, heat, and the uncomfortable structure of standard helmets as reasons for non-use [32
The availability and accessibility of cheap and non-standard helmets in the market, as reported by the participants in this study, calls for the government to play a more regulatory role. Discontinuing the manufacture and distribution of non-standard helmets, subsidizing the cost of standard helmets for low-income families, and enforcing regulations that ban the import of non-standard helmets, may increase the likelihood of purchasing and using standard safety helmets among motorcyclists.
It might be suggested that the reactions reported in the study were the result of risk appraisals associated with the consequences of helmet non-use or misuse. However, we did not directly assess participants' risk perceptions, therefore, we cannot categorize the participants into any specific risk groups. Wilde [34
] argues that individuals subconsciously and/or consciously weigh the advantages and disadvantages of choosing target levels of risks. He suggests that the cognitive process of risk assessment is determined by the individual's past experiences, assessment of his/her potential risks for getting into an accident, and the degree of confidence the individual has in his/her skills to handle a vehicle. According to the Wilde's theory, people look for a certain level of thrill in their lives; therefore, behaviors with zero risk usually don't catch their attention. To change the risky reactions of riders to the helmet law, it is important to identify where along the continuum of risk-taking they are and how ready they are to change those reactions. This may allow interventionists to properly match risk-reduction programs with the readiness level of the target audience. Respondents in our study seem to fall somewhere along this continuum of risk assessment. Further studies are needed to assess the role of "risk perception" in provoking various reactions to the helmet laws.
Furthermore, studies are needed to assess the impact of the "culture of masculinity" in promoting risky reactions toward safety helmet laws, among male motorcyclists. This "culture of masculinity" promotes uptake of certain values and behaviors among men. For example, men are expected to be emotionally distant and rational, and behaviorally, aggressive, tough, and autonomous [35
]. Men who adopt these beliefs and behaviors are more likely to engage in activities that compromise their health and threaten their longevity [36
]. From the social constructionist perspective, social practices in which men engage are the means for demonstrating masculinity [37
]. Within this perspective, motorcycling or joining the police force in Iran facilitates the presentation of a masculine persona among men.
The use of motorcycles in the construction of masculinity underlines the importance of gender-specific interventions. This kind of intervention can build on what the culture of masculinity idealizes -- that men are expected to provide for their family as the main breadwinner -- and so empower men as responsible individuals.
Some investigators suggest motorcyclists should be motivated to properly and consistently use safety helmets [28
]. Others suggest educational programs are needed to inform consumers of the specifications of standard and non-standard safety helmets, as well as, their proper usage and injury prevention functions [3
]. Another group contends that reinforcement measures provide deterrent to non-compliant motorcyclists when they are enforced appropriately and consistently [38
]. Nonetheless, the endorsement of the safety helmet law without providing adequate socio-culturally sensitive educations and interventions may result in unfavorable outcomes. As shown by the results of this study, these laws might lead to further reckless behaviors.
Reinforcement measures along with educational programs that consider the overall culture of motorcycle riding in Iran are highly recommended [8
]. These programs can promote and motivate safe riding by increasing motorcyclists' awareness of the danger of risky and reckless ridings, informing them about existing laws and the risks of being detected, explaining the physical, legal, and financial consequences of non-complaint reactions to the helmet law. Intervention programs should strive to overcome possible barriers related to: (1) A 'culture of masculinity' which might promote risk tolerance among male motorcyclists and a disposition toward lawlessness and carelessness; and (2) motorcyclists' misinterpretation of the laws. In Iran, especially after the Islamic revolution of 1979, religion and family have played an important role in holding individuals responsible for their own health and safety of the others. In the Quran one is taught; "to stay away from self-harm" and "caution not to harm others" [39
]. However, there is a paucity of scientific evidence showing an association between the role of family and religion in promoting helmet safety use among motorcyclists. A retrospective study among 166 junior and high school students reported that students with a "high family norm of bicycle helmet use" were more likely to use helmets than student who came from families with a "low family norm". Similarly, student who grew up in a bicycle-friendly community were more likely to use helmet more often [41
]. A different study reported that a parent-child intervention yields positive outcome in the helmet use of their adolescent child [42
]. Motivational interventions are needed to evaluate the impact of the local culture, family role, and religious messages in promoting the use of safety helmets among motorcyclists.
At the same time, a lack of consistency in enforcing the traffic laws by the enforcement officers (according to our findings) calls for the system-level interventions. Regular law-enforcement training programs and/or workshops for the in-service enforcement officers can help law enforcement officers to better understand and share problems and concerns in providing good law-enforcement services. Training goals should be based on periodic assessments of enforcement activities of the officers so that the content of training matches with the officers' existing needs. Findings of this study imply that traffic enforcement officers could advantage from training workshops that will increase their knowledge and skills to act decisively and motivate them to improve their compliance with the traffic-law enforcement goals and established policies.
This study has the inherent limitation of any qualitative research -- the findings are limited by design and not generalizable to the larger motorcyclist population. Other limitations of the study included the following: (1) we did not directly assess the variable 'perception of risk', which might influence certain reactions among the participants; and (2) this study could not offer any gender-related information about the reactions of motorcyclists to the safety helmet law.
Despite these limitations, our method has followed four essential aspects of a qualitative analysis [43
]: (1) the inclusion criteria were relevant to the research question; (2) data collection methods (i.e. focus-group discussions and in-depth interviews) were appropriate for the specific aim of the study; (3) data collection processes were rigorous and comprehensive to support saturation and robust descriptions of the information collected; (4) data was analyzed appropriately and results were corroborated by using multiple reviewers to ensure that participants' viewpoints were adequately interpreted.
Furthermore, our results offer some insights into research that is not well established, and therefore, can be built upon in further studies. Risk appraisals may be performed on un-helmeted riders to better understand the perception of the physical, legal, and financial factors that contribute to the risky reactions to the helmet laws.