With the help of a research grant from the Highland Primary Care NHS Trust, I conducted a research project at the CairnGorm Mountain ski area during the winter 2001/02. What follows is my report on this study - to those of you who took part in it, my sincerest thanks. We have already fed this information back to the ski areas and other interested parties.
This study was picked up by the UK media and was misreported to say the least in some quarters! Read it for yourself before making your mind up!
Dr Mike Langran
Introduction
There are approximately 280,000 visits to Scottish ski areas every winter season. Of this population, about 1200 individuals (0.4% of the total visitor number) sustain a snow sports related injury requiring medical attention. More than half of these injuries occur at ski areas within the Highland Primary Care NHS Trust area and, of these, about 33% affect snowboarders. The overall management of these injured individuals puts considerable pressure on the Scottish Ambulance Service and certain local general practices as well as hospital accident/emergency and orthopaedic services. There is a larger additional cost to society in general in terms of time off work, social security benefits and the consequences of longer-term disability.
Of the available snow sports, alpine skiing and snowboarding account for 65% and 26% respectively of all ski area customers. The epidemiology of the injury patterns associated with both sports is now well known. This has lead to the development of equipment designed to protect against injury. The uptake of such protective equipment (for example, ski brakes and releasable ski bindings) after its introduction was very high amongst the alpine ski population with a consequential 50% reduction in the associated injury rate for this sport. Its now virtually impossible to buy skis without these features built in. Unfortunately, the uptake of safety equipment by snowboarders has been slower. Snowboarding is associated with higher levels of injury to the upper limb and wrist fractures in particular compared to skiing - although one must remember that the absolute risk is still very low. Many of these injuries occur at high speed and result in serious bony injuries requiring operative orthopaedic intervention and follow-up. Several studies have now shown that the use of wrist guards can reduce the risk of upper limb injury by between 35-50%. Ongoing research carried out by the author indicates that the use of wrist guards by the total snowboard population is slowly rising, but still averages less than 10%. Amongst injured snowboarders, only 6% were wearing wrist guards. No previous studies have considered why these rates are so low. The hypothesis is that a lack of knowledge of the associated injury risks and a risk-taking culture amongst snowboarders are at least partly to blame. Other factors including the cost and availability of protective equipment and the perceived image of wearing wrist guards and helmets may also be relevant.
The aims of this project were therefore to assess the following factors amongst uninjured snow-boarders in Scotland:
1. Level of injury risk awareness
2. Attitudes towards risk-taking behaviour
3. Attitudes towards the use of protective equipment
And relate this to parameters such as age, gender, level of snowboard experience and use of professional instruction.
Methods
An anonymous questionnaire containing 18 separate questions was developed for use in this study (see appendix). The questions covered basic demographics, previous snowboarding experience and knowledge of injury risk. Snowboarders’ attitudes towards the use of protective equipment and knowledge and attitudes towards injury risk whilst snowboarding were also explored. The questionnaire was designed so that ‘perceived’ and ‘actual’ risk taking scores could be calculated for each individual who replied. This allowed a sub-group analysis to be performed comparing snowboarders who were categorised as high risk-takers with all other snowboarders. High-risk snowboarders were defined as those who admitted intentionally taking a moderate or high-level of risk whilst boarding and who also perceived the activities associated with the sport to constitute a low risk to themselves. Over the course of the winter season 2001-2002, questionnaires were distributed to 900 snowboarders selected at random in the main car park as they left the CairnGorm Mountain Ski Area. Those aged less than 16 years and those who had sustained an injury in the current season were excluded. The nature of the study was explained in person to each snowboarder. Those who agreed to participate in the study were given an envelope pack containing an explanatory letter, the questionnaire and a stamped addressed envelope for reply. The car park area was chosen to reduce the potential for selection bias that may have occurred at other sites on the ski area (where the population may be skewed towards a particular ability group – e.g. beginners). Additionally, it was considered that snowboarders would be more receptive to an approach for cooperation at the end of their snowboarding day than at any other time when their priority would be, understandably, to continue snowboarding. Questionnaires were returned by post to the principal investigator at the Aviemore Medical Practice. The results were coded, entered into a Microsoft Access database and then converted into both SPSS and Stata files for statistical analysis. Statistical significance was accepted at p values of less than 0.5
Results - [The tables are displayed as links in pdf format]
256 questionnaires were returned (response rate 28.4%). The demographic details of respondents are shown in Table 1. For interest’s sake, these details were compared to those of the larger control snowboard population (n=510) obtained from the ongoing Scottish Snow Sports Safety Study (4S study). Although no statistical analysis has been performed, it can be seen that the two populations are broadly similar, except that a larger number of snowboarders in the current study had taken some form of professional instruction. Of those respondents who had not taken lessons, the reasons cited included having received informal instruction from friends (23.4%), not seeing the need for lessons (12.8%), that lessons were too expensive (9.6%) and that the respondent did not like the idea of taking instruction (2.1%). The remaining 52.1% who had never received instruction declined to state their reasons.
122 respondents (47.7%) reported sustaining a previous injury whilst snowboarding – 43.4% of these consulted a doctor as a result. Of those who did not attend a doctor, 28.8% reported that the injury was either minor or that they treated it themselves.
Participants were asked to estimate the injury rate for snowboarding, and to identify the area of the body most likely to be injured whilst snowboarding (Tables 2 & 3). The correct injury rate of 1-5 injuries per 1000 snowboard days was identified by only 16.4% of respondents. 32.8% believed that injuries were sustained at a rate of more than 20 per 1000 snowboard days. The majority of respondents correctly identified the wrist as the most likely anatomical area to be injured snowboarding.
Helmets were worn by 33 (12.9%) of respondents, although of these only 42.4% reported being happy to do so. 19.1% of respondents reported wearing wrist guards whilst snowboarding and a lower percentage (30.6%) said they were happy to do so. Of those not wearing a helmet or wrist guards, the reasons cited are tabulated in Table 4. Given a choice, 86.1% of respondents stated that they would prefer a wrist guard system inside, rather than outside, their gloves. Interestingly, those who correctly identified the wrist as the most likely area to be injured also reported a higher incidence of wrist guard use (25% vs 13%, p=0.021).
The final section of the questionnaire concentrated on the individual’s personal perception of risk and risk-taking whilst snowboarding. Respondents were firstly asked to stratify the inherent level of risk they themselves would be taking whilst performing four common snowboarding manoeuvres – travelling at speed on piste, performing a jump, using a half-pipe and using a tow lift. The results are shown in Table 5.
Discussion
This study has provided valuable information about knowledge levels and attitudes towards injury risk amongst a cohort of snowboarders in Scotland. Demographically, the group is similar in characteristics to the general snowboard population in Scotland. Several important questions were answered by this study that will assist in the development of future education programs aimed at reducing the incidence of snowboard related injuries:
- Compared to alpine skiers, it has been a consistent finding that a smaller percentage of snowboarders take professional lessons. This study has confirmed the hypothesis that many snowboarders prefer informal instruction from friends. This instruction is unlikely to cover the same range of issues as professional instruction and may sow the seeds of poor technique, ignorance of general mountain safety and the importance and proven value of protective equipment. It also makes it more likely that inexperienced boarders will be tempted to try pistes beyond their level of competence in order to keep up with their more experienced
- Nearly 50% of respondents reported sustaining a previous injury snowboarding. It is impossible to grade the severity of these injuries accurately but 4 out of 10 required medical attention. There was a high tendency to self-treat minor injuries. Emphasis could be placed on ensuring that snowboarders are aware of the correct method of treating soft tissue injuries and when to seek
- The majority of snowboarders over-estimated the risk of an injury whilst snowboarding. More than half correctly identified the wrist as the main site of injury.
- More snowboarders reported wearing wrist guards than helmets. The main reason cited for not wearing either piece of equipment was “no need”. Helmets were perceived as expensive and uncomfortable. Wrist guards were also felt to be uncomfortable and also difficult to get hold of. Nearly a quarter of snowboarders were unaware of the existence of wrist guards. Given a choice, most would choose a guard system inside the glove. These findings have major implications in any campaign to increase the use of wrist guards and helmets in Scotland.
Study limitations
It is acknowledged that this study has several inherent weaknesses that must be taken into account when interpreting the results presented. Firstly, the respondents may not be representative of the general snowboard population in Scotland. Less than one third of all questionnaires were returned. It is likely that those who did reply represent a slightly different sub-population of individuals more interested in the topic. Although the comparison with the control population from the larger 4S study shows only one noticeable difference (uptake of professional instruction) this nevertheless represents a potentially major difference. Furthermore, the study was targeted at snowboarders aged over 16 years in order to ensure informed consent was obtained. This would naturally exclude a proportion of the actual total snowboard population. The study relied on honesty and accuracy in reporting by participants. Both the questionnaire and covering letter were carefully worded to avoid any suggestion of the expected findings, hopefully reducing intentional inaccurate reporting to a minimum. The author has many year’s experience of collecting data from both injured and uninjured snowboarders and was unable to identify any obvious fictitious replies. Whilst acknowledging these potential confounding factors, the author would argue that the study nevertheless provides a useful insight into snowboarders’ attitudes and knowledge levels that has not been reported previously.
Conclusions
This pilot study has provided a valuable insight into the knowledge and attitudes of a cohort of snowboarders in Scotland. Future education programs aimed at improving injury awareness strategies amongst snowboarders will need to take these issues into account. Whilst protective devices such as helmets and wrist guards are currently available, snowboarders have highlighted several concerns that impede their widespread use. These concerns need to be addressed by (amongst others) manufacturers and retailers if the use of protective equipment is to increase. The identification of factors that define a high-risk snowboarder will help in the targeting of such a group for injury prevention. The real challenge will be to develop this education in a format that is acceptable and relevant to such individuals.
Acknowledgements
This study was funded by a research grant from the Highland Primary Care NHS Trust Central Endowments Fund. The author would also like to acknowledge the cooperation and guidance of the following individuals and organisations, without whose assistance this study would not have been possible:
S. Selvaraj (Highlands and Islands Health Research Institute)
Dr H Richards, Mrs S Railton (Highlands and Islands Health Research
CairnGorm Mountain
Dr Cheryl Tallon
Reception staff, Aviemore Medical Practice
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