Spatial Study of Mortality in Motorcycle Accidents in the State of Pernambuco, Northeastern Brazil

OBJECTIVE: To analyze the spatial distribution of mortality due to motorcycle accidents in the state of Pernambuco, Northeastern Brazil. METHODS: A population-based ecological study using data on mortality in motorcycle accidents from 01/01/2000 to 12/31/2005. The analysis units were the municipalities. For the spatial distribution analysis, an average mortality rate was calculated, using deaths from motorcycle accidents recorded in the Mortality Information System as the numerator, and as the denominator the population of the mid-period. Spatial analysis techniques, mortality smoothing coeffi cient estimate by the local empirical Bayesian method and Moran scatterplot, applied to the digital cartographic base of Pernambuco were used. RESULTS: The average mortality rate for motorcycle accidents in Pernambuco was 3.47 per 100 thousand inhabitants. Of the 185 municipalities, 16 were part of fi ve clusters identifi ed with average mortality rates ranging from 5.66 to 11.66 per 100 thousand inhabitants, and were considered critical areas. Three clusters are located in the area known as sertão and two in the agreste of the state. CONCLUSIONS: The risk of dying from a motorcycle accident is greater in conglomerate areas outside the metropolitan axis, and intervention measures should consider the economic, social and cultural contexts.


INTRODUCTION
Transport accidents are "epidemic" in societies today and enter the public health agenda along with morbidity and mortality from external causes.
Motorcycle riders stand out among the victims of transport accidents in Brazil.The use of motorcycles for transportation and labor increases signifi cantly and rapidly, especially in the interior of the Northeastern Brazil.The mortality rate for this category has been rising sharply since the mid-1990s. 8,10a a Ministério da Saúde.Departamento de Informática do Sistema Único de Saúde.Sistema de Informação sobre Mortalidade -SIM [CD-ROM].Brasília, DF: Secretaria de Vigilância em Saúde; s.d.
Motoboy couriers and mototaxis are new forms of employment and paid passenger transportation increasingly used by businesses and individuals.
Detecting areas where such accidents happen can be the fi rst step to help develop intervention measures. 5echniques of geographic distribution and spatial statistic knowledge are important tools for epidemiological studies of accidents.Spatial analysis techniques allow the identifi cation of sites with greater risk of accidents so as to defi ne spatial clusters of events as particular focus of high incidence b or of high-intensity events.Thus, this study aimed at analyzing the spatial distribution of mortality due to motorcycle accidents in the state of Pernambuco.

METHODS
Population-based ecological study using data on mortality in motorcycle accidents in the state of Pernambuco from January 1 st , 2000 to December 31, 2005.
The analysis units consisted of the municipalities and development regions in the state, namely: Metropolitana; Mata Norte, Mata Sul, Agreste Setentrional, Agreste Meridional, Agreste Central, Sertão do Pajeú, Sertão do Moxotó, Sertão de Itaparica, Sertão Central Sertão do São Francisco, Sertão do Araripe.This regionalization takes into account common aspects regarding culture, politics, economy and territory of each cluster of municipalities, according to State Law No. 12,427 of 9/25/2003.We included all deaths from transport accidents in the group "motorcycle rider injured in transport accident" (V20-29) of the International Classifi cation of Diseases 10 th revision (ICD-10), as registered in the Sistema de Informação sobre Mortalidade (SIM -Brazilian Mortality Information System) among residents of the state of Pernambuco.The average mortality rates were reached using as the numerator the number of deaths in motorcycle accidents and as the denominator the mid-period population (as of 12/31/2002).For the census years, the reference population was based on the estimated population for municipalities given by the Instituto Brasileiro de Geografi a e Estatística (IBGE -Brazilian Institute of Geography and Statistics).We used spatial analysis techniques, smoothing coeffi cient by the local empirical Bayesian method and the Moran scatterplot, applied to the digital cartographic base of the state.So as to correct random fl uctuations in small populations or small occurrence numbers, we re-estimated mortality rates using the local empirical Bayesian method under the assumption that rates in surrounding areas are autocorrelated.c Moran's index is used to summarize the spatial distribution of data, identifying clusters of areas with similar risks for occurrence of the outcome of analysis.Conceptually, this index ranges from -1 to 1: values near zero indicate a lack of spatial correlation -the difference between neighbors; positive values indicate positive spatial autocorrelation, i.e. the existence of similarities between neighboring municipalities; and negative values represent negative spacial autocorrelation.Moran's index was used to analyze the extent to which the level of a variable in an area is similar to that in neighboring areas. 9itical areas and areas of transition were identifi ed with the Moran scatterplot, used to compare the values of each municipality studied with the neighboring municipalities' and to visualize spatial dependence, and the spatial patterns.Municipalities enclosed in the MoranMAP Q1 class were considered critical areas.
The exploratory spatial analysis seeking to identify the transition areas and the critical areas of the studied events were carried out on Excel © spreadsheets and on the TerraView version 3.14.© software.The results were represented in the digital cartographic base of Pernambuco.

RESULTS
The average mortality rate for motorcycle accidents in the state of Pernambuco was 3.47 per 100 thousand inhabitants.We identifi ed fi ve critical areas formed by 16 of the 185 municipalities in the state.These areas had mortality rates ranging from 5.66 to 11.66/100,000 inhabitants, higher than the state average.Two of these areas were located in developing regions of the Pernambuco Agreste and the other three in developing regions of the Sertão.The municipality of Calumbi, situated in the Pajeú Sertão, had the highest motorcycle mortality rate, nine times higher than that reported in Recife (the state capital), where there is a higher number of vehicles in circulation.
The municipalities with the lowest values were located in developing regions of the Mata Sul and Mata Norte, and in the Metropolitan region (Figure 1).

The coefficient correction by the local empirical
Bayesian estimate smoothed the areas, specifying the municipalities with higher mortality rates in motorcycle accidents, located in developing regions in the Sertão and sub-areas in the Agreste (Figure 2).
Q1 municipalities were located in the developing regions of the Agreste and of the Sertão, and the transitional areas (Q3 and Q4) in the vicinity of the Recife Metropolitan Region (in the coast) and in developing regions of the Sertão of the state, respectively (Figure 3) .
Clusters with a statistical signifi cance of 5% were identifi ed using information from the Moran Map (Figure 4).4).

DISCUSSION
The study identifi ed areas of Pernambuco in which motorcycle accident mortality is higher, particularly in the municipalities located in the developing regions of the Agreste and Sertão.This exploratory stage becomes strategic for the prevention and reduction of morbidity and mortality by highlighting the need for research on the social determinants in these critical areas, in these clusters. 6Moreover, the aspects that differentiate the accidents in which the motorcycle is used as working tool from those in which it is restricted to a means of transportation must be investigated.Mean mortality rate per 100 thousand inhabitants

Meters
The tranquility of small and medium sized cities has been broken with the arrival of "the modern".
Transportation technologies help transform social life, provide greater well-being, facilitate and reduce the travel time, and bring people together, but also lead many others to death, with a high cost to society.The  The answer to this phenomenon, coming from common sense, as is often the case with the media and the constituted authorities, is directed to the culpability of the victim.They believe that education, law enforcement and engineering will solve the problem of traffi c accidents.However, the day-to-day reality shows that addressing the issues of violence in traffi c orientated by the triad man-vehicle-track is obsolete.Souza et al d claim that the violence, including traffi c violence, is not a disease for which one has a specifi c medicine.It is part of human relationships and the dynamics of society: it dramatizes social issues.Societal actions towards democracy and inclusion seem to be, historically, the best solution.
According to Mello Jorge, 7 when studying the genesis of traffi c violence "one is faced with a multifaceted and pluriform event, which involves various kinds of factors, making it clear that any approach to be made to that effect should be intersectoral and multidisciplinary".
Specific actions aimed at changing motorcyclist behavior have little effect, 11 since traffi c accidents with motorcyclists are not just related to driving behavior.They are about the milieu and the market rules established by employers and clients.
The production of motorcycles in Brazil grew by almost 600% from 1996 (288,073 units) to 2008 (2,004,815), according to the Brazilian Association of Manufacturers of Motorcycles, Mopeds and Similar Vehicles.The increase in the national motorcyclist mortality rate per 100,000 inhabitants in the period 1996-2006 followed this curve: 660%, but reached 875% in Pernambuco.However, the growth in motorcycle production seen throughout the country and also in Pernambuco should not be taken as the sole explanation for the increase in motorcycle accidents.One of the limitations of this study is an inability to identify the critical points of accidents within each municipality, given that risk is not homogeneous throughout.
The prevention of occupational and traffi c accidents is traditionally based on the concept of "behavioral safety", in which obedience to rules is suffi cient to reduce accidents.This conception is dominant even among experts in the industry and hegemonic in common sense.Thus, unsafe acts and unsafe conditions would be the cause of accidents.¹Recent studies show limitations of these models that leave out "the causes of the causes" of accidents and "inhibit effective prevention practices " . 4It is necessary to enlarge conceptually the analysis of accident determinants, replacing the
The quadrants generated by this technique are interpreted as follows: Q1 (Positive values, positive means) and Q2 (Negative values, negative means), indicating points of positive spatial association or of similarities among neighboring areas; Q3 (Positive values, negative means) and Q4 (Negative values, positive means), indicating points of negative spatial association, i.e., municipalities which have different values from neighboring areas.Cluster areas of motorcycle accidents were identifi ed in the following steps: 1. Location of areas that have positive spatial relationship (Q1), given by values in the Moran scatterplot, and visually represented by BoxMAP; 2. Construction of the MoranMAP considering the areas that have a positive spatial relationship identifi ed by BoxMAP and with a spacial signifi cance equal to or below 5%.

Figure 2 .Figure 3 .
Figure 2. Mean mortality rate due to motorcycle accidents estimated by the local empirical Bayesian method.Pernambuco, Northeastern Brazil, 2000-2005.Mean mortality rate per 100 thousand inhabitants
Three clusters located in the developing regions of the Sertão of Pernambuco and two developing regions of the Agreste of the state were considered critical locations.These clusters comprise the municipalities of Ouricuri, Trindade and Ipubi, in the developing region of the Sertão do Araripe; Serra Talhada, Santa Cruz da Baixa Verde, Triunfo, Calumbi e Betânia, in the developing regions of the Sertão do Pajeú and the Sertão do Moxotó; Petrolina, Afrânio and Lagoa Grande, in the developing region of the Sertão do São Francisco; and Brejo, Tacaimbó, São Caetano, Saloá and Bom Conselho, in the developing regions of the Agreste Central and Meridional of Pernambuco (Figure paradigms, for others such as: a systemic view and complex thought used in the theoretical model developed by Macías.e It is believed that in modern times, this is the path able to reveal suitable alternatives to reduce traffi c accidents, especially those involving motorcycles.