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Abstract
Background Nova Scotia is the first jurisdiction in the world to mandate ski and snowboard helmet use for all ages at ski hills in the province. This study represents a longitudinal examination of the effects of social marketing, educational campaigns and the introduction of helmet legislation on all-age snow sport helmet use in Nova Scotia.
Methods A baseline observational study was conducted to establish the threshold of ski and snowboarding helmet use. Based on focus groups and interviews, a social marketing campaign was designed and implemented to address factors influencing helmet use. A prelegislation observational study assessed the effects of social marketing and educational promotion on helmet use. After all-age snow sport helmet legislation was enacted and enforced, a postlegislation observational study was conducted to determine helmet use prevalence.
Results Baseline data revealed that 74% of skiers and snowboarders were using helmets, of which 80% were females and 70% were males. Helmet use was high in children (96%), but decreased with increasing age. Following educational and social marketing campaigns, overall helmet use increased to 90%. After helmet legislation was enacted, 100% compliance was observed at ski hills in Nova Scotia.
Conclusions Results from this study demonstrate that a multifaceted approach, including education, legislation and enforcement, was effective in achieving full helmet compliance among all ages of skiers and snowboarders.
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Introduction
Traumatic brain injuries (TBIs) are a devastating type of injury among skiers and snowboarders that can have serious consequences for individuals, families and the health system. Increasing attention has been paid recently to the effectiveness of helmets at reducing injury and death among this population, with estimates of up to a 60% reduction of injury and death.1 In the majority of jurisdictions, helmet use while downhill skiing or snowboarding is voluntary; however, some jurisdictions have opted to mandate helmet use for children and youth only.2 Evaluations of age-specific policies demonstrate that helmet use declines once it is no longer mandatory, even when educational campaigns are ongoing.3 Similar effects have been demonstrated with legislation requiring bicycle helmets for certain age groups.4
Although helmet use was not required for children visiting the ski hill with a parent or guardian in Nova Scotia, surveillance conducted in 2010 demonstrated that voluntary usage was high among younger age groups; particularly those aged 4–12 years.5 These observations demonstrated that after the age of 12 years helmet use declined sharply with age, with the lowest rates among those skiers and snowboarders aged 60 years and older.
Research has demonstrated that public policy is an effective strategy for behaviour change and promoting health and safety.6 Nova Scotia is the first jurisdiction in the world to mandate ski and snowboard helmet use for all ages at ski hills in the province. The Snow Sport Helmet Act7 was passed through legislation on 11 December 2011 and then proclaimed as law on 1 November 2012. The Act applies to downhill skiing and snowboarding. Helmets must comply with the existing approved standards as outlined in the regulations. Individuals over the age of 16 are liable for their own helmet use, with parents or guardians responsible for children under the age of 16.
In partnership with Nova Scotia's ski hills, data on helmet use rates were collected prelegislation and postlegislation. The purpose of this current study was to assess the extent to which the education, marketing and the Snow Sport Helmet Act were effective at increasing helmet use among skiers and snowboarders.
Methods
Baseline observational study
A previously reported winter sport helmet study using a mixed methods approach was conducted during the 2009–2010 ski season to examine helmet use and factors associated with helmet use. Selected data from this study form the source of our baseline study.5 Naturalistic observations consisting of 15 min sessions were conducted at both the base and top of all types of lifts for all ski hill entrances/locations at the province's three fully operational ski hills. Four visits were conducted per ski hill, consisting of a day (12:00–16:00) and night (16:01–22:00) observation session on both weekdays and weekends, to ensure different sampling times and to capture various skiing levels (school trips, competitive events and novice to expert recreational participants). Standardised interviews were conducted to explore factors influencing helmet use or non-use on these slopes and to identify factors that might inform potential education and marketing strategies. A consistent study methodology for the helmet observational studies was maintained through all study years. Structured interviews and falls data collection were only conducted in the baseline year.5
Wear it Proud! campaign
In an effort to increase voluntary helmet use among downhill skiers and snowboarders, the Government of Nova Scotia supported the development and implementation of a campaign based on qualitative and quantitative data from the 2009–2010 observational study.5 Wear it Proud! was launched in the 2010–2011 ski season and was designed to create a positive social norm for helmet use, to increase awareness of helmet effectiveness and to correct the misperception that only half of skiers and snowboarders in Nova Scotia wore helmets. The Wear It Proud! campaign was developed to celebrate helmet hair resulting from helmet use. Ski and snowboard helmet wearers were asked to submit photos of their helmet hair for a chance to win prizes such as a ski trip to Mont Tremblant, Quebec.
Prelegislation observational study
Naturalistic observations for helmet use using the same methodology as baseline data collection in 2010 were completed at Nova Scotia's three fully operational ski hills during the 2011–2012 ski season. Helmet Match, a marketing campaign, was launched in February 2012 to create awareness of the impending ‘Snow Sport Helmet Act’ and was used to educate skiers on proper helmet fit and industry standards of four approved certifications under the Snow Sport Helmet Act Regulations—Canadian Standards Association (CSA), American Society for Testing and Materials (ASTM), European Standard (EN) or Snell Memorial Foundation (SNELL). The observation study was conducted prior to the launch of the Helmet Match campaign.
Postlegislation observational study
Legislation was proclaimed on 1 November 2012 and enforced in the 2013 ski season. A postlegislation observational study was conducted in 2013 using the same methodology described in our previous work.5 Project timelines are illustrated in figure 1.
Project timelines.
The Capital Health Research Ethics Board approved this series of studies (REB # CDHA-RS/2010-283).
Descriptive statistics, including frequencies of gender, age group, sport type and skiers/snowboarders on each ski hill, were used to characterise the data.
Results
Table 1 shows the sample demographics for all 3 years.
Population demographics for all years
Baseline observational study
In total, 3337 observations were made, of which 74% of skiers and snowboarders were using helmets prior to the legislation.5 Helmet use differed between females and males (80% and 70%, respectively; χ2=38.5, p<0.001). Helmet use was the highest among children 4–12 years (96%), but there was a decreasing trend in helmet use with increasing age (figure 3).
Protection was the main reason cited by helmet users to favour their use, whereas non-helmet users cited social norms as the major cause for not wearing helmets. Minimal resistance to the legislation was anticipated due to the findings of focus group interviews in which teen and adult skiers and snowboarders said that they would continue to ski and snowboard even if there was a mandatory rule in place.
Wear it Proud! campaign
There were over 300 skiers and snowboarders who had their photos taken for Wear it Proud! The site had just under 55 000 visits and almost 15 000 votes were cast in the contest.
Prelegislation observational study
A total of 4354 observations were made including 2811 skiers and 1543 snowboarders. With increased awareness through education and marketing, overall helmet use increased to 90% in 2012 (figure 2). Nearly all children and 97% of adolescents were wearing helmets. See figure 3 for the breakdown of helmet use by gender and age.
Prevalence of overall snow sport helmet use over three observational study years.
Snow sport helmet use by (A) gender, (B) age, (C) sport (skiing vs. snowboarding) and (D) ski hill.
The Helmet Match educational campaign was launched in preparation for the enactment of legislation. The campaign website received 1426 unique visitors, 50% of which arrived at the site via external links such as those from the three participating ski hills and the Nova Scotia government.
Postlegislation observational study
Naturalistic observations were completed in January and February 2013, after the enactment of the Snow Sport Helmet Act. In total, 3887 skiers and snowboarders were observed, and there was 100% compliance with the Snow Sport Helmet Act.
Participation rates
Management at the ski hills were very concerned about participation rates. Data on participation were obtained independently by management of each of the ski hills. Ski hills reported that the legislation did not impact participation rates on their hills; specific numbers were not made available to the authors.
Discussion
Most skiers and snowboarders (74%) were voluntarily wearing helmets on Nova Scotia ski hills prior to increased education and social marketing due to a positive pre-existing helmet culture. Provincial skier and snowboarder populations were ready for legislation, which may in part have been due to strong provincial helmet laws for other wheeled activities, such as bicycle riding and recent campaigns to mandate helmet use in ice skating.8 To fully influence the helmet non-users (10%), education, marketing and all-age helmet legislation were employed resulting in 100% helmet use in the 2012–2013 winter season, without decreased participation in skiing and snowboarding.
TBIs and spinal cord injuries from skiing and snowboarding are an important contributing cause of hospitalisation, long-term disability and fatality from winter recreational sports. In an attempt to evaluate the efficacy of helmets in skiing and snowboarding, recent evidence-based reviews have demonstrated that safety helmets clearly decrease the risk and severity of TBIs, and do not enhance risk compensation behaviour or the risk of neck injury from wearing helmets.9 ,10
According to the 2011–2012 National Ski Areas Association (NSAA) National Demographic Study, 67% of skiers and snowboarders in the USA wore helmets while enjoying the slopes.11 Children aged 10–14 years comprised 81% of the helmeted population, but merely 53% of those aged 18–24 years were wearing helmets. There is a lack of mandatory helmet policies in the USA, with the exception of New Jersey, which passed legislation mandating helmets for children younger than 18 years of age.12 Among European countries, Italy,13 Austria,14 Croatia13 and Norway2 have enacted similar legislation for children over the past few years.
Canadian snow sport helmet usage is challenging to estimate; to date, Nova Scotia is the only province to have all-age helmet legislation. Existing published reports indicate that in addition to the Mountain Code of Conduct, terrain parks in Quebec are regulated to post signage for terrain park riders. Other provincial ski resort regulations and requirements for helmets vary.
Recent reports suggest that most skiers (71%) in Canada wear helmets.15 In line with NSAA National Demographic Study, the vast majority of children aged 10–14 years wore helmets (95%). Young adults (18–24 years) wore helmets 63% of the time, whereas adult (35–44 years) helmet usage was 69%. In keeping with the statistics from the Canadian Ski Council, our baseline study reported children's helmet use at 95.6%, adolescent helmet usage at 80% and a drop to 65.7% in adults. This trend demonstrated decreasing helmet usage with increasing age despite public education efforts, and supported the need for all-age legislation.
Educational campaigns and helmet laws have been shown to increase helmet use compliance. Conversely, there is a decrease in helmet use in the absence of helmet laws.3 ,16 In children, the decision to wear a helmet is strongly influenced by parental use; children whose parents wear snow sport helmets are more likely to use helmets themselves.17 In adults, factors influencing helmet use are variable and may include style, perceived skill level and personal knowledge of traumatic or non-TBI resulting from skiing/snowboarding. Some authors speculate that cognitive dissonance plays a role in refusal to wear protective helmets even when the benefits are evident.13 Although public awareness and educational campaigns have increased snow sport helmet use globally, there remains a subgroup of the adolescent and adult population who are not fully influenced by helmet promotion campaigns. The results of our study show that when these efforts are bolstered by ski helmet legislation and enforcement, behavioural change towards helmet use in the adolescent and adult population can be effected.
In many jurisdictions, ski helmets are not considered fashionable and are not yet part of the ski slope and ski resort culture.18 This lack of social norm has hindered jurisdictions from promoting and enforcing ski and snowboarding helmet use. We recognise that our success is in part due to the collaborative partnerships that were formed between ski hill operators, government public health officials, social media marketing agencies and academic health centres. This voluntary association between multisectorial partners, who share a common interest and commitment in improving snow sport safety, led to the shared success of this project with minimal public resistance to legislation. We used a multifaceted approach to affect behaviour change in skiers and snowboarders around the importance of helmets in preventing brain injuries and staying safe on the slopes.
Education: Wear it Proud! and Helmet Match were social marketing campaigns developed through a collaborative partnership between various ski injury prevention stakeholders. Through both campaigns, the public was educated regarding the importance of wearing a helmet and the rules of proper helmet fit, and were provided with incentives to encourage helmet use.
Enactment of legislation: In Canada, Nova Scotia is the only province with a ski and snowboard helmet law that applies to all ages. It was prompted by concerns over the devastating outcomes of brain injury and the costly medical care associated with managing TBIs. Previous work has shown that in the absence of helmet laws, helmet use declines in adolescents, leaving snow sport participants in this age group at risk for head injuries.3
Enforcement: Ski hills are liable for displaying signage provided by the provincial government in specified areas that informs skiers and snowboarders of the law and the approved list of helmets. All of the province's ski hills have helmets available for rental. The provincial government had provided grants to the ski hills when the law was enacted, to assist in building up rental stocks of approved helmets.
The Snow Sport Helmet Act is enforced by public health inspectors employed by the provincial government. Ski hills are inspected two times per month during the skiing season and inspectors generally spend 2 h at the hill per visit. Inspectors observe individuals approaching the lifts or coming down the hill. If an individual is observed not wearing a helmet as required by the Act or if the required signage is not displayed, the inspectors have the authority to issue a summary offence ticket.
Out-of-court settlements for these offences at the time of publication were $406.45 for any person downhill skiing or snowboarding without wearing a required helmet or with chin strap of helmet not securely fastened, or for permitting a person under 16 to ski or snowboard without wearing a required helmet. The fine for failure to display required signage was $291.45.
In the first 2 months of enforcement during the 2012–2013 ski season, inspectors issued warnings and allowed individuals who were not compliant with the Act the opportunity to retrieve their helmet or rent one from the ski hill. All of the ski hills were compliant with the requirement to display signage. Two of the ski hills assisted in enforcement by requiring downhill skiers and snowboarders to wear a helmet before they were allowed to use any of the lifts by ski hill staff. At these hills, compliance was 100% upon inspection.
The study has limitations inherent to any observational analysis. Observers used their best estimate based on appearance for gender and age group determination given that skiers and snowboarders were not stopped to obtain demographic information. Therefore, subgrouping of study participants by gender and age was subject to possible observer bias. It was difficult to determine the isolated effect of educational awareness, legislation and enforcement on snow sport helmet use over the study period. As a result, the cumulative effect of these multifaceted approaches in achieving all-age snow sport helmet compliance is reported. Although a randomised controlled trial would be highly desirable to demonstrate the effects of a multifaceted approach, there are practical and ethical limitations of such a study design. Given the evidence-based benefits of bicycle helmet use, it would be challenging to meet the criteria for clinical equipoise, which is necessary for ethical randomisation to helmet/non-helmet use.
Conclusion
This series of snow sport helmet studies examines the progression of research evidence translated into legislative change with the overall goal to improve health and safety for skiers and snowboarders. To fully achieve widespread all-age helmet use at ski hills in Nova Scotia, we implemented a multipronged, staged approach of education, legislation and enforcement. Our success was likely due to the synergistic effect of multifaceted approaches over time as well as the readiness of the provincial population. Based on our experience, we recommend the promotion and enforcement of all-age skiing and snowboarding helmet laws to prevent TBIs and their long-term consequences.
What is already known on this subject
Traumatic brain injuries contribute significantly to injury-related deaths in skiers and snowboarders.
Helmets can help prevent brain injuries, but the impact of an all-age snow sport helmet law is unknown.
What this study adds
An all-age snow sport helmet law can be successfully implemented with no significant impact on overall participation.
A multifaceted approach using a combination of education, legislation and enforcement can help achieve all-age helmet use.
Acknowledgments
We acknowledge the support of Health Promotion Student Interns, Jacob Landry (2009–10) and Nicole Gorman (2011–12), for their assistance with data collection and data entry. Andy MacLean (Martock) acted as the liaison to the ski hill communities. This research was conducted in collaboration with the Nova Scotia ski hills: Ben Eoin, Martock and Wentworth.
References
Footnotes
Contributors LF contributed to overall study design, implementation, coordination, data acquisition and manuscript preparation and editing. JH contributed to data collection, marketing campaigns and manuscript preparation and editing. JY contributed to study conceptualisation, data collection and editing. GT-H contributed to data entry, data analysis and manuscript preparation. NK and BB contributed to data analysis and manuscript preparation. SW contributed to study design and manuscript editing. DBC generated the study's conceptual framework and design and manuscript editing.
Funding Nova Scotia Department of Health and Wellness as well as Dalhousie University Division of Neurosurgery.
Competing interests None declared.
Ethics approval Capital Health Research Ethics Board.
Provenance and peer review Not commissioned; externally peer reviewed.