Gender disparities in observed motorcycle helmet use in Madagascar: female motorcyclists behave safer but have lower overall protection

Although motorcycle helmets can save lives in case of a crash, no helmet use data are available for many countries. When data is available, it is often only analysed as a global average, preventing targeted road safety education and legislative action. In this study, we conducted a detailed analysis of motorcycle helmet use in the capital of Madagascar.Using a cross-sectional observational field survey framework, we observed 17 230 individual motorcycles. We systematically recorded motorcycle riders' helmet use, position on the motorcycle, rider numbers and gender.We found a general helmet use of 76.1%. Observed drivers had a significantly higher helmet use (84.6%) than passengers (47.7%), and subsequently helmet use per motorcycle decreased significantly when the number of riders per motorcycle increased. Female drivers had significantly higher helmet use than male drivers, and female passengers had significantly higher helmet use than male passengers. That is, on the same position of the motorcycle, female riders behaved safer than male riders. However, since female riders were more often passengers than drivers, their average helmet use was lower than that of male riders overall. Contrary to findings from other countries, motorcycle helmet use did not differ significantly throughout the day but was relatively constant.Our results show the potential for injury and fatality prevention in Madagascar through increased passenger helmet use. This increase would also proportionally benefit female riders more than male riders. Findings regarding road safety legislation's applied impact, education, enforcement and future research needs are discussed.