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Ski helmets reduce the risk of traumatic brain injury (TBI), but usage rates are low. Ski patrollers could serve as role models for helmet use, but little is known about their practices and beliefs.
A written survey was distributed to ski patrollers attending continuing education conferences.
helmet use rates; prior TBI experiences; perceptions of helmet risks and benefits; and willingness to serve as safety role models for the public. To assess predictors of helmet use, odds ratios were calculated, after adjusting for skiing experience.
Ninety-three ski patrollers participated.
Self-reported helmet use of 100% while patrolling.
Helmet use was 23% (95% CI 15–32%). Common reasons for non-use included impaired hearing (35%) and discomfort (29%). Most patrollers believed helmets prevent injuries (90%; 95% CI 84–96%) and that they are safety role models (92%; 95% CI 86–98%). However, many believed helmets encourage recklessness (39%; 95% CI 29–49%) and increase injury risks (16%; 95% CI 7–25%). Three factors predicted 100% helmet use: perceived protection from exposure (OR = 9.68; 95% CI 3.14–29.82) or cold (OR = 5.68; 95% CI 1.27–25.42); and belief that role modeling is an advantage of helmets (OR = 4.06; 95% CI 1.29–12.83). Patrollers who believed helmets encourage recklessness were 8 times less likely to wear helmets (OR = 0.13; 95% CI 0.03–0.58).
Ski patrollers know helmets reduce serious injury and believe they are role models for the public, but most do not wear helmets regularly. To increase helmet use, manufacturers should address hearing- and comfort-related factors. Education programs should address the belief that helmets encourage recklessness and stress role modeling as a professional responsibility.
Alpine skiing and snowboarding are popular recreational activities, although they are associated with some degree of risk. There were an estimated 10.6 million snowsports participants in the United States during the 2006–2007 season; there were 22 reported fatalities, representing 0.40 fatalities per million participant-days (National Ski Association, www.nsaa.org/nsaa/press/facts-ski-snbd-safety.asp). For comparison, the fatality rate among recreational bicyclers (0.42 fatalities per million participant-days) is almost identical (National Ski Association, www.nsaa.org/nsaa/press/facts-ski-snbd-safety.asp).
A large proportion of skier and snowboarder fatalities are attributable to traumatic brain injury (TBI). One study of 149 fatal skier and snowboarder injuries in Colorado attributed death to TBI in 42.2% of adults and 66.7% of children (Xiang & Stallones, 2003; Xiang, Stallones, Smith, 2004). A separate trauma registry review found that 29% of skiing- and snowboarding-related hospital admissions and 87.5% of fatalities were caused by TBI (Levy, Hawkes, Hemminger, Lee & Knight, 2002).
Not surprisingly, the issue of helmet use in skiing and snowboarding has been the target of mainstream media coverage as well as extensive clinical, epidemiologic and biomechanics research (Brooke, 1998, January 7; Janofsky 2002, March 31; Kenworthy, 1998, January 1). In 1999 the United States Consumer Product Safety Commission estimated that 44% of all snowsports-related TBIs (and 53% in children) could be prevented by helmet use (Consumer Product Safety Commission, 1999). More recent studies have demonstrated a 29–60% TBI risk reduction (and a 66% reduction in severe TBI) among helmet users (Hagel, Pless, Goulet, Platt & Robitaille, 2005; Sulheim, Holme, Ekeland & Bahr, 2006).
Helmet use among recreational skiers and snowboarders remains suboptimal, although it has increased in recent years. In a 2006–2007 survey of more than 68,000 skiers and snowboarders, 40% indicated that they were wearing a helmet at the time of sampling, compared with only 25% in 2002 (National Ski Areas Association, 2007). A variety of strategies have been proposed to increase helmet use among skiers and snowboarders, including educational campaigns, helmet use requirements, legislation and helmet giveaway programs (McClellan, 2002, May 1; Michigan House Bill 5628, 94th legislature, regular session of 2008; National Ski Areas Association, www.LidsOnKids.org; National Ski Areas Association, www.nsaa.org/nsaa/press/0708/nsaw-08-events.asp; Pennington, 2007, January 26; Utah Department of Health, 2004, December 3; Vermont Snow Sports Research Team, 2007). Yet, little attention has been paid to ski patrollers, who could serve as highly visible role models for helmet use. Indeed, according to the “prestige bias” theory from social psychology, members of a population will preferentially copy those whom they view as prestigious or highly skilled (Henrich & Gil-White, 2001; Richerson & Boyd, 2005). However, little is known about the attitudes and practices of ski patrollers regarding helmet use, nor about their willingness to serve as role models for the skiing and snowboarding public.
The overall objective of this study was to assess the practices, attitudes and beliefs of ski patrollers regarding helmet use. Specifically, we sought to determine: a) self-reported helmet use among ski patrollers; b) ski patrollers’ beliefs regarding the benefits, risks or discomforts associated with helmet use; c) whether ski patrollers’ use of helmets was associated with age, ski patrol experience, prior head injury or other factors; d) common reasons for helmet non-use; and e) the degree to which ski patrollers accept, or reject, the argument that they should serve as role models for safe skiing and snowboarding.
A 16-item questionnaire was distributed to a convenience sample of volunteer and paid ski patrollers who were attending continuing education lectures covering a variety of ski patrol-related medical topics. The survey was offered between 2004 and 2006 to members of four different Colorado ski patrols. The survey was also sent by email to the entire distribution list of one additional volunteer ski patrol. None of the ski areas required that patrollers wear helmets when on duty. All participants were 18 years of age or older. The survey was voluntary and took approximately five minutes to complete. Informed consent was obtained from all participants. The study was reviewed and approved as exempt by the institutional review board.
The survey included demographic and personal variables addressing age, gender, skiing or snowboarding ability level and seasons of experience. Respondents were asked if they have children who ski or snowboard and if they require their children to wear a helmet. The remaining questions were designed to measure ski patrollers’ experiences, attitudes, practices, and beliefs in four domains: a) helmet ownership and frequency of use while patrolling; b) helmet use during other recreational activities; c) history of a skiing- or snowboarding-related injury or TBI involving the ski patroller or “someone close;” and d) beliefs regarding the risks, benefits and discomforts of helmet use. We also asked participants whether ski patrollers should serve as role models for safety. Two questions addressed this topic: a) “Do you see yourself as a positive role model for children and adults who are learning to ski or snowboard?” and b) “Is serving as a positive role model an advantage to wearing a helmet?”
The majority of the survey questions were presented in a yes-no format. For example, participants were asked, “Do you believe that ski helmets reduce serious injuries?” and “Have you or someone close to you been seriously injured while skiing or snowboarding?” For the variable “age,” participants were asked to select one of four categories: 18–25; 26–35; 36–45; or over 45 years. Skiing or snowboarding proficiency was categorized by participants as I (Beginner), II (Intermediate) or III (Advanced). Experience (total seasons skiing or snowboarding) was recorded as a continuous variable. Participants were provided a list of potential reasons for helmet non-use (for example, “cannot hear my radio” and “I am an expert skier”) and were instructed to “check all that apply.” After pilot testing, the questions and response options were revised to improve clarity and content validity.
The principal objective of this study was to measure full-time helmet use during patrol-related skiing and snowboarding. Therefore, “helmet use” was defined as wearing a helmet 100% of the time. All other responses (0–99%) were considered helmet non-use.
The analysis of the survey data proceeded in two steps. First, demographic characteristics of participants and their survey responses were summarized using means and standard deviations or medians and ranges for continuous variables and proportions and 95% confidence intervals for categorical variables.
Second, bivariate analyses were performed to test for associations between the principal outcome (100% helmet use) and a variety of ski patroller characteristics. These included: age; gender; skiing or snowboarding experience; parental status; and beliefs regarding the risks and benefits of helmet use. To measure the strength of the associations between each of these variables and helmet use, odds ratios (ORs) and 95% confidence intervals were calculated, after adjusting for skiing experience. Adjustment was performed using standard Cochran-Mantel-Haenszel statistics, after defining two strata of experience (less than 20 seasons vs. 20 seasons or more). The decision to calculate experience-adjusted ORs was made a priori, as it was felt that seasons of skiing or snowboarding experience is likely to influence the knowledge, experiences and attitudes of ski patrollers regarding helmets as well as the decision to wear a helmet. Survey participants were not required to answer every question. Question-specific response rates ranged from 74–100%.
Surveys were returned by a convenience sample of 93 ski patrollers. Two-thirds of the patrollers were men, and 70% were 45 years of age or younger (Table 1). Most participants were skiers (72%) and were highly experienced (median = 27, range = 4–28 seasons); almost all (97%) considered themselves to be experts. Almost half of survey participants (49%) had prior experience with a serious injury involving themselves or someone close to them; 23% of participants reported a prior experience with a serious TBI.
Only 23% (95% CI 15–32%) of ski patrollers reported that they always wore a helmet during patrol skiing; 26% (95% CI 17–35%) reported they were part-time users (1–99%), and 51% (95% CI 40–61%) reported never wearing one.
As summarized in Table 2, most participants (94%; 95% CI 89–99%) believed there is some safety advantage to wearing a helmet; the majority also believed that helmets reduce the risk of a serious injury (90%; 95% CI 84–96%). However, 39% (95 CI 29–49%) of survey participants believed that helmet use encourages reckless skiing and snowboarding, while 16% (95% CI 7–25%) believed that helmets can increase injury severity.
Seventeen percent of participants said they had children under age 18 who ski or snowboard; the majority of these parents (75%; 95% CI 54–96%) required that their children wear helmets.
The reasons cited by patrollers for not wearing a helmet are listed in Table 3. The most common reasons were related to hearing and comfort, while factors such as style and price were the least often mentioned.
Helmet use was not associated with age, gender, ability level, snowsports experience, TBI experience or having children involved in snowsports. Helmet use was also not associated with the belief that there are safety advantages to wearing a helmet or with the belief that helmets reduce injury risks.
As shown in Table 4, three factors were positively associated with 100% helmet use: the belief that helmets protect against environmental exposure (OR = 9.68; 95% CI 3.14–29.82); the belief that helmets provide warmth (OR = 5.68; 95% CI 1.27–25.42); and the belief that “serving as a role model” is an important advantage of wearing a helmet (OR = 4.06; 95% CI 1.29–12.83). One belief was strongly associated with helmet non-use: Patrollers who believed that wearing a helmet encourages reckless skiing or snowboarding were almost eight times more likely not to wear a helmet regularly while patrolling (OR = 0.13; 95% CI 0.03–0.58).
More than 92% (95% CI 86–98%) of ski patrollers viewed themselves as a “positive role model for children and adults who are learning to ski or snowboard.” However, there was no association between acceptance of this role and helmet use (OR = 1.46; 95% CI 0.16–13.71). There was also no association between belief that ski patrollers are positive role models and any of the other predictor variables (age, gender, snow sport type, ability level, experience, professional or volunteer patrol status, prior injury to self or someone close, prior TBI to self or someone close or having children who ski or snowboard).
This study has several important limitations. It is based on a small convenience sample, collected from a limited number of ski areas in a single state. The small sample size limits the precision of our results and the power to detect associations between experiences, attitudes and beliefs and helmet use. Additionally, we could not collect any information about the larger population of ski patrollers from whom our small sample was drawn; therefore, we cannot assess the direction or magnitude of any nonparticipation bias. Also, all of the data were derived from self-reports of helmet use, experiences and beliefs, and there is no assurance that the responses are reliable or valid. The survey did not include detailed definitions of terms such as “serious traumatic brain injury,” “serious injury,” or “reckless skiing.” Finally, the survey was distributed at medical education conferences. There is the possibility that selection bias was introduced, because conference attendees may have been more aware of skiing- and snowboarding-related hazards or other medical issues. Recall bias (of previous TBI experiences) may also have resulted from the medical nature of the conferences.
This study provides new information about the practices and beliefs of ski patrollers regarding helmet use, and about their willingness to serve as role models for the skiing and snowboarding public. We are not aware of any other published studies examining this topic.
The results suggest that there is a discordance between the beliefs of ski patrollers and their behavior. Patrollers are convinced that helmets reduce serious injury, that they serve as role models for other skiers and snowboarders, and that serving as a role model is a benefit of wearing a helmet. Nevertheless, only a minority (23%) wear helmets all of the time. They cited hearing- and comfort-related factors most often as reasons for helmet non-use. While a large majority knew that helmets reduce the risk of TBI, sizeable proportions felt that helmets also encourage reckless skiing or increase the risk of injury.
Importantly, the belief that helmets encourage recklessness was a strong predictor of helmet non-use. Thus, this study suggests that a large proportion of ski patrollers adhere to the “risk compensation,” or “risk homeostasis,” theory. This idea posits that individuals who use helmets – like those who use safety belts, gun safety locks, back country avalanche beacons or other protective devices – will respond to the intervention by increasing their risk-taking behavior to meet an intrinsic level of acceptable risk, negating the overall preventative effects of the intervention (Hagel, 2004; Hedlund, 2000). To date, research specific to skiing and snowboarding has not demonstrated a significant increase in at-risk behaviors or in non-head traumatic injuries (reflecting speed or recklessness) among helmet users (Hagel, Pless, Goulet, Platt & Robitaille, 2005; Macnab, Smith, Gagnon & Macnab, 2002; Scott et al., 2007). Nonetheless, this misconception was prevalent among the ski patrollers we questioned, and it was strongly associated with helmet non-use. Education programs aimed at countering this belief could be an effective method to increase helmet use among professional ski patrollers.
The current study also demonstrated that a large proportion of ski patrollers accepted the label of “positive role model” for safe skiing and snowboarding, and a majority of respondents felt that acting as a role model is a reason to wear a helmet. However, no one has measured whether role modeling or helmet use by ski patrollers is important or influential from the skiing and snowboarding public’s point of view.
This study identifies a number of interventions that could increase helmet use by ski patrollers. Manufacturers should be encouraged to address hearing, vision and comfort-related factors, since patrollers identified these as the most common barriers to regular helmet use. Educational programs for ski patrollers should also be designed to address the misconceptions identified in this study. The patrollers in our sample were well aware that helmets reduce the risk of TBI. However, 16% of patrollers believed that helmets increase the risk of serious injury, and nearly 40% believed that helmets encourage reckless skiing (the risk compensation theory). The latter perception was a strong predictor of helmet non-use. These beliefs should be addressed in ski patrollers’ educational curricula, using the best available scientific evidence. Indeed, current biomechanical and epidemiologic data demonstrate that helmets reduce the incidence and severity of TBI, which accounts for a large portion of morbidity and mortality among skiers and snowboarders.
Helmet use among the skiing and snowboarding public remains suboptimal, and further measures are needed to increase helmet use and decrease the risk of TBI. This study identifies ski patrollers as potential role models for helmet use. Most ski patrollers accept this role, and educational interventions could be developed to reinforce the role of wearing a helmet as part of ski patrollers’ professional responsibilities. At the same time, additional studies should be performed to measure the impact of ski patrollers’ behavior on the attitudes and behaviors of the general public.
BE was involved in study conception and design, data collection, result interpretation, manuscript revision and final approval. JG was involved in data collection, result interpretation, writing of the first draft of the paper, manuscript revision and final approval. KH was involved in result interpretation, manuscript revision and final approval. MV was involved in data analysis, result interpretation, manuscript revision and final approval. SL was involved in study design, data analysis, result interpretation, manuscript revision and final approval.
Dr. Lowenstein is supported in part by Grant Number R49/CCR811509 from the Centers for Disease Control and Prevention. The contents of this paper are solely the responsibility of the authors and do not necessarily represent the official views of the CDCP.
Bruce Evans, Division of Emergency Medicine, Department of Surgery and the Colorado Emergency Medicine Research Center. University of Colorado Denver School of Medicine. Leprino Office Building, 7th Floor 12401 E. 17th Avenue B215, Aurora, Colorado, USA 80045. Telephone: 720-848-6777; Fax: 720-848-7374; Email: ude.revnedcu@snavE.ecurB.
Jack T. Gervais, University of Colorado Denver School of Medicine. Leprino Office Building, 7th Floor 12401 E. 17th Avenue B215, Aurora, Colorado, USA 80045. Telephone: 720-848-6777; Fax: 720-848-7374; Email: moc.oohay@08siavregkcaj.
Kennon Heard, Division of Emergency Medicine, Department of Surgery and the Colorado Emergency Medicine Research Center. University of Colorado Denver School of Medicine. Leprino Office Building, 7th Floor 12401 E. 17th Avenue B215, Aurora, Colorado, USA 80045. Telephone: 720-848-6777; Fax: 720-848-7374; Email: ude.revnedcu@draeH.nonneK.
Morgan Valley, Division of Emergency Medicine, Department of Surgery and the Colorado Emergency Medicine Research Center. University of Colorado Denver School of Medicine. Leprino Office Building, 7th Floor 12401 E. 17th Avenue B215, Aurora, Colorado, USA 80045. Telephone: 720-848-6781; Fax: 720-848-7374; Email: ude.revnedcu@yellaV.nagroM.
Steven R. Lowenstein, Departments of Surgery, Medicine and Preventive Medicine/Biometrics. University of Colorado Denver School of Medicine. Leprino Office Building, 7th Floor 12401 E. 17th Avenue B215, Aurora, Colorado, USA 80045. Telephone: 720-848-6789; Fax: 720-848-7374; email: ude.revnedcu@nietsnewoL.nevetS.