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Attitudes regarding ski helmet use among helmet wearers and non-wearers
  1. Gerhard Ruedl1,
  2. Martin Kopp1,
  3. Gerhard Rumpold2,
  4. Bernhard Holzner3,
  5. Larissa Ledochowski1,
  6. Martin Burtscher1
  1. 1Department of Sport Science, University of Innsbruck, Innsbruck, Austria
  2. 2Department of Medical Psychology, Innsbruck Medical University, Austria
  3. 3Department of Biological Psychiatry, Innsbruck Medical University, Austria
  1. Correspondence to Dr Gerhard Ruedl, Department of Sport Science of the University of Innsbruck, Fürstenweg 185, 6020 Innsbruck, Austria; gerhard.ruedl{at}uibk.ac.at

Abstract

Objective The aim of this study was to compare attitudes regarding ski helmet use in helmet wearers and non-wearers.

Methods In total, 924 persons ≥18 years (52% men and 48% women) participating in sport programmes at the University Sports Institute Innsbruck/Austria were interviewed about their attitudes regarding ski helmets and scored 14 statements on a five-level Likert Scale. A factor analysis was employed to determine clusters of underlying attitudes that have subsequently been used as predictors of helmet non-use in a conditional logistic regression analysis.

Results In total, 65% of participants declared to use a helmet during their preferred winter sport activity while more than 80% of helmet wearers and non-wearers totally agreed that helmets protect from head injuries. According to the factor analysis, attitudes about ski helmets clustered around four major dimensions—subjective disadvantages, safety awareness, comfort/style and risk compensation. Adjusted ORs of regression analysis showed that helmet non-use increased with age and decreased with increasing skill level (beginner: OR 5.4, 95% CI 2.6 to 11.1; intermediate: OR 4.3, 95% CI 2.4 to 7.9; advanced: OR 3.1, 95% CI 1.7 to 5.4). In addition, helmet non-use was associated with subjective disadvantages (OR 2.3, 95% CI 1.8 to 2.9). However, a negative association between helmet non-use and safety awareness (OR 0.3, 95% CI 0.2 to 0.4) was found.

Conclusion Helmet use was associated with higher safety awareness, while most arguments against helmet use seem to belong to subjective perception and to represent anticipatory negative cognitions, poorly supported by evidence. Therefore, evidence-based information about wearing a ski helmet should be implemented in preventive helmet campaigns focusing on non-wearers. In addition, health communication programmes should be instituted to get non-helmeted skiers and snowboarders to try out helmets to eliminate their potential prejudices.

  • Ski helmet
  • attitudes
  • alpine skiing
  • snowboarding
  • head injury
  • risk factor research
  • epidemiology
  • sports/leisure facility
  • risk perception
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Introduction

In alpine skiing and snowboarding, head injuries account for 9% to 19% of all injuries reported by ski patrols and emergency departments.1 2 Severe head injuries include traumatic brain injury, which is a leading cause of traumatic deaths among winter sport participants.2 However, Russel et al2 found in their recently published meta-analysis that ski helmet use could reduce head injury risk by 35%. Well in accordance, we found that helmet use was associated with a 28% reduction in the risk for head injury.1 Over the last 10 years, ski helmet use has steadily increased worldwide in part as a result of preventive helmet campaigns and in part as a result of increased media coverage after fatal injuries involving celebrities.1 3–5 In Austria, ski helmet use has increased to more than 60% in 2009.6 However, ski helmet use seems to be related to various factors like age, nationality and skill level.6 We demonstrated that helmet use was significantly higher in younger age than in older age, significantly higher in locals than in tourists and higher in more-skilled skiers than in less-skilled skiers.6 Common reasons reported for helmet non-use are an increasing level of risk taking and impaired hearing and impaired vision.7–11 More knowledge about attitudes would be helpful for preventive campaigns to increase helmet use.12 Therefore, the goal of the present study was to compare attitudes regarding ski helmet use in helmet wearers and non-wearers.

Methods

After obtaining Institutional Review Board approval, people ≥18 years participating in sport programmes at the University Sports Institute Innsbruck/Austria were interviewed about their attitudes regarding ski helmets in October 2010. We recorded information on gender, age, nationality, preferred winter sport (skiing vs snowboarding vs back country skiing) and self-estimated skill level (expert, advanced, intermediate, beginner) according to Sulheim et al13 and whether a helmet is used during winter sport activities. In addition, participants scored 14 statements about ski helmets (table 1) on a five-level Likert Scale (I disagree totally—I rather disagree—I disagree/agree partly—I rather agree—I agree totally). The standardised interview took about 5 min. Informed consent was obtained from all subjects prior to participating in this research.

Table 1

Attitudes regarding statements about ski helmets of helmet wearers and non-wearers

Statistical analysis

Mann–Whitney U tests were used to compare helmet wearers and non-wearers with regard to age. χ2 tests were used to assess different frequencies between groups with regard to gender, nationality, type of gear used, skill level and attitudes regarding ski helmets. Cronbach's α was calculated to determine the internal consistency of the 14 items. Since analysing each of the 14 Likert items separately increases the probability of a type I error, a principal components factor analysis with Varimax rotations was employed to determine clusters of underlying attitudes. These calculated dimensions of underlying attitudes have subsequently been used as predictors of helmet non-use in a conditional logistic regression analysis including also age and skill level. Adjusted ORs and their 95% CIs have been calculated. All p values were two-tailed and values <0.05 were considered to indicate statistical significance.

Results

In total, 924 persons (51.6% men and 48.4% women) with a mean age of 31.8±13.1 years were interviewed. The preferred winter sport was alpine skiing in 61.5%, snowboarding in 24.7% and back country skiing in 13.9% of the participants. Helmet use was practiced by 65.3% of the participants, with no differences within gender (p=0.515) as well as within preferred sports (p=0.959). Helmet wearers did not differ with regard to nationality compared to non-wearers (p=0.191). Helmet wearers were younger (30.8±12.1 vs 33.8±14.6 years, p=0.014) and had a higher proportion of advanced and expert skiers compared to non-wearers (70.6% vs 54.8%, p<0.001).

Cronbach's α for the internal consistency of the 14 items was 0.69. Univariate comparisons of attitudes of helmet wearers and non-wearers are shown in table 1.

Ski helmet wearers and non-wearers did not differ significantly (p>0.05) regarding attitudes that helmets protect from head injuries, that adults wearing helmets are role models for children and that ski helmets increase risk-taking behaviour. More than 80% and more than 78% of helmet wearers and non-wearers totally agreed that helmets protect from head injuries and that adults wearing helmets are role models for children, respectively. Only about 8% of wearers and non-wearers totally agreed that a ski helmet increases risk taking.

Regarding all other attitudes, helmet wearers and non-wearers differed significantly (p<0.05). Helmet wearers totally disagreed about twofold more often compared to non-wearers that helmets interfere with vision (53% vs 26%) and hearing (16% vs 8%) as well as that helmets are uncomfortable (46% vs 17%) and heavyweight (61% vs 34%).

In addition, helmet wearers totally agreed more often compared to non-wearers that helmets are stylish (19% vs 7%) and warm the head when weather is cold (55% vs 37%) as well as that all winter sport participants (66% vs 30%) and all children (93% vs 84%) should wear helmets. In contrast, non-wearers totally agreed more often compared to helmet wearers that helmets are expensive (17% vs 9%) and that helmets damage hairstyle (26% vs 25%) as well as that people using a helmet sweat when weather is warm (36% vs 27%).

In table 2, factor analysis of the 14 five-point Likert Scale statements showed that the attitudes about ski helmets clustered around four major dimensions—subjective disadvantages (Cronbach's α=0.59), safety awareness (Cronbach's α=0.52), comfort/style (Cronbach's α=0.51) and risk compensation. Together, these four dimensions accounted for 48% of the variability in the attitudes.

Table 2

Ski helmet attitudes and factor loading (N=916)

Multivariate regression analysis revealed four factors to be significantly predictive for helmet non-use: age, skill level, subjective disadvantages and safety awareness (table 3). Adjusted ORs of regression analysis showed that helmet non-use increased with age and decreased with increasing skill level (beginner: OR 5.4, 95% CI 2.6 to 11.1; intermediate: OR 4.3, 95% CI 2.4 to 7.9; advanced: OR 3.1, 95% CI 1.7 to 5.4). In addition, helmet non-use was associated with subjective disadvantages (OR 2.3, 95% CI 1.8 to 2.9). However, a negative association between helmet non-use and safety awareness (OR 0.3, 95% CI 0.2 to 0.4) was found.

Table 3

Multivariate ORs of predictive factors for helmet non-use

Discussion

The aim of the present study was to compare attitudes regarding ski helmets between helmet wearers and non-wearers. Multivariate regression analysis revealed four factors to be significantly predictive for helmet non-use: age, skill level, subjective disadvantages and safety awareness. Helmet non-use was associated with older age, less skill level, higher subjective disadvantages and less safety awareness.

Helmet use in the present study was about 65%, which is well in accordance with the findings from our previous study where we also found no differences in helmet use with regard to gender and type of gear used.6 Also, the higher helmet rate in younger skiers in the present study is well in accordance with other findings.6 12 14 In addition, we found that helmet non-use increased with decreasing skill level being in agreement with other studies3 6 15

The factor ‘subjective disadvantages’ including attitudes about hearing, vision, sweating, hairstyle, costs and weight was highly predictive for helmet non-use. We found a total agreement that a ski helmet interferes with hearing in 12% of helmet wearers and about 20% of non-wearers. In comparison, 35% of interviewed ski patrollers believed that helmets impair hearing.7 A study by Tudor et al11 showed that ski helmets could raise the hearing threshold of frequencies between 2 kHz and 8 kHz, which are characteristic of the hissing caused by a skier or snowboarder passing closely by or breaking behind. However, sound was not attenuated at the frequencies characteristic of the human voice (<1 kHz), so that warning shouts should be heard.11

In a study by Evans et al,7 about a quarter of interviewed ski patrollers felt that ski helmets interfere with vision. Also, in the present study, about 11% of helmet wearers and about 22% of non-wearers rather or totally agreed that a ski helmet may interfere with vision. In a recent pilot study, however, we demonstrated that ski helmets did not affect reaction time to peripheral stimuli.16 Besides, our results indicated that ski goggles increased mean reaction time to peripheral stimuli.16

Sweating with a ski helmet when weather is warm was totally agreed upon by 27% of wearers and 36% of non-wearers (p<0.05). Also, 30% of interviewed ski patrollers found that helmets are hot.7 However, a study reported a mean temperature of −4±5.1°C during the 2008/2009 winter season in Austrian ski resorts.17 Therefore, during the majority of the winter season, helmets should warm the head rather than cause sweating.

About a quarter of helmet wearers and non-wearers found that a helmet damages one's hairstyle. However, head protection should be more important than hairstyle for skiers, as a study by Greve et al18 showed that most head injuries (74%) occurred when the skier hit his head on the snow while 10% and 13% occurred upon collision with other skiers and fixed objects, respectively.

A total agreement that helmets are expensive was found in only 9% of wearers and about 17% of non-wearers. In comparison, 8% of ski patrollers found that helmets are expensive.7 Also, Peterson and Brooks19 stated that helmet cost is a minor barrier in their study. Considering potential costs of a medical treatment after a head injury,20 costs for a ski helmet should be negligible.

About 61% of wearers and 34% of non-wearers totally disagreed that helmets are heavyweight. Although the weight of helmets was associated with higher neck injury risk, especially in children, a recently published study21 did not suggest that helmets increased the risk of neck injuries among skiers and snowboarders.

The factor ‘safety awareness’ was negatively associated with helmet non-use; that is, skiers with higher safety awareness are more likely to wear ski helmets. Recent studies showed that helmet use reduced head injury risk up to 60% in children and adults.1 2 14 In addition, helmet use is associated with reduced rates of skull fractures among hospitalised children.22 According to Evans et al,7 about 90% of interviewed ski patrollers believed that a helmet reduces the risk of a serious head injury although only 23% of them always wore a helmet. Also, more than 80% of helmet wearers and non-wearers in the present study totally agreed that helmet use protects from head injuries. In the study by Evans et al,7 about 90% of ski patrollers believed to be safety role models when wearing helmets. In the present study, most helmet wearers and non-wearers concurred that adults using ski helmets are role models for children (85% vs 79%). Jung et al4 reported that children whose parents used ski helmets themselves wore significantly more frequently ski helmets than did children whose parents did not wear a helmet. Cundy et al12 found that a key reason for the high helmet usage in children was that their parents ‘make them’ wear a helmet because parents may place greater emphasis on the safety of their children than on their own when skiing or snowboarding. In accordance, in the present study, most helmet wearers and non-wearers stated that all children on ski slopes should wear ski helmets (93% vs 84%). In contrast, 66% of helmet wearers and 30% of non-wearers totally agreed that all winter sport participants should wear a ski helmet. However, one third of helmet wearers did not totally support this statement, which might be due to the fact that they do not support any kind of compulsory helmet use that would constrict their freedom of choice. In comparison, about 40% of people in the study by Jung et al4 did not favour compulsory use of helmets for skiing. In the past years, advocates for legislated mandatory helmet use as well as those who encouraged voluntary helmet use were growing.12 Studies concerning the mandatory use of bicycle helmets found that the main effect of legislation was to discourage cycling rather than to encourage helmet wearing.12 23 According to Cundy et al,12 a possible pragmatic alternative is to implement non-legislative helmet promotion campaigns.

Surprisingly, about one third of non-wearers advocated helmet use for all winter sport participants. This result can be explained by Prochaska's transtheoretical model of behaviour change, which suggests that persons move from one stage of change to another until they eventually incorporate a healthy action into a regular behaviour pattern.24 25 In contrast to the first stage, ‘precontemplation’, where persons have no interest in making a change, persons in the second stage, ‘contemplation’, start to weigh the pros and cons of their actual behaviour24 25; specific information in this period might foster at least the preparation of behaviour change. In the study by Jung et al,4 about 14% of interviewed persons stated that they bought a helmet following the media coverage after fatal injuries involving celebrities in 2009 and about 21% planned to buy a helmet in future.

Regarding the factor ‘comfort/style’, about 55% of helmet wearers and about 37% of non-wearers totally agreed that a helmet warms the head. In comparison, in a study by Evans et al,7 67% of ski patrollers found that helmet use provides the advantage of warmth, and in a study by Cundy et al,12 more than 50% of children and adults using a helmet found that a helmet keeps their head warm. In our study, only 3% of wearers and 13% of non-wearers stated that helmets are uncomfortable. Also, 8% of wearers and 22% of non-wearers totally disagreed that helmets are stylish. However, manufacturers of ski helmets continuously try to improve air ventilation, weight, comfort and style of their products. In addition, regression analysis revealed that comfort/style was not predictive for helmet non-use.

In accordance with the so-called risk compensation hypothesis, which is based on the assumption that safety appliances such as ski helmets cause a false sense of security in their users, a controversial discussion regarding the potential influence of wearing a ski helmet on the level of risk-taking behaviour took place in recent years.9 10 14 In the present study, however, only about 8% of helmet wearers and non-wearers totally agreed that helmet use increases risk taking. In addition, our regression analysis revealed that the factor ‘risk compensation’ was not predictive for helmet non-use. Several studies also indicated that ski helmet use is not necessarily associated with riskier behaviour on ski slopes.9 10

While there is little disagreement on the important features of helmets, that they save lives, that they do not promote risk compensation and that adults wearing helmets are positive role models, helmeted and non-helmeted skiers differed in far less fundamental issues (eg, hearing, hairstyle, costs), which might be more amenable to attitude change. Therefore, health communication programmes should be instituted to get non-helmeted skiers and snowboarders to try out helmets to eliminate their potential prejudices. According to a study by Andersen et al,3 helmet campaigns should be based on the Trialability from Diffusion of Innovation Theory26 because the ability to use an innovation for a trial period is positively correlated with its rate of adoption.3

A few limitations have to be considered. Interviews were taken before the ski season started at the University Sports Institute instead on a ski slope. Therefore, actual helmet use and practising the preferred winter sport could not be proved. In addition, a possible selection bias cannot entirely be excluded because only participants of sport programmes at the University Sports Institute, who may be on average more sportive and may have a higher grade of education compared to the average skiing population, were interviewed. However, several studies3 6 15 have suggested that both education and skiing experience are associated with higher helmet use.

In conclusion, helmet use was associated with higher safety awareness while most arguments against helmet use seem to belong to subjective perception and to represent anticipatory negative cognitions, poorly supported by evidence. Therefore, it seems of utmost importance to provide evidence-based information about the advantages of wearing a ski helmet. Keeping in mind the transtheoretical model of behaviour change, this information should be implemented in preventive helmet campaigns focusing on non-wearers in the contemplation stage to increase helmet use on ski slopes. In addition, health communication programmes should be instituted to get non-helmeted skiers and snowboarders to try out helmets to eliminate their potential prejudices.

What is already known on the subject

  • Over the last 10 years, ski helmet use has steadily increased.

  • Helmet use decreases head injury risk in alpine skiing and snowboarding.

  • Common reasons reported in the literature for non-use are an increased level of risk taking, impaired hearing and impaired vision.

What this study adds

  • There was little disagreement between wearers and non-wearers on the important features of helmets, that they save lives, that they do not promote risk compensation and that adults wearing helmets are positive role models. Helmeted and non-helmeted skiers differed in far less fundamental issues such as hearing, hairstyle and costs.

  • Arguments against helmet use are poorly substantiated by evidence.

  • Evidence-based information about wearing a ski helmet should be implemented in preventive helmet campaigns focusing on non-wearers.

Acknowledgments

The authors thank the participating students for their help in conducting interviews.

References

View Abstract

Footnotes

  • Competing interests None.

  • Ethich approval This study was conducted with the approval of the Institutional Review Board Sport Science, University of Innsbruck.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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