Personal Protective Equipment Use By In-Line Skaters in Victoria

Shauna Sherker & Erin Cassell
Monash University Accident Research Centre

(Aust N Z J Public Health 2001; 25: 179-184) Accepted: February 2001

Abstract

Objective: To describe use of personal protective equipment (PPE) by in-line skaters at four different skate settings (rink, park, trail and 'street') in Melbourne and rural Victoria, and to compare local PPE use with reported international use.

Method: Unobtrusive observations of in-line skaters at 4 types of skate settings (rinks, parks, trails, street) in Melbourne and rural Victoria.
Results: Two thirds of 490 observed in-line skaters (66.7%) wore none of the recommended PPE (wrist guards, elbow and knee pads and helmets). Only 2.2% wore all four pieces of PPE. Wrist guards were worn by 25.9% of skaters, knee pads by 23.5%, elbow pads by 6.9% and helmets by 5.5%. Younger skaters were least likely to wear any PPE. Trail skaters were more likely to wear PPE than skaters on rinks, parks and streets. Almost one-third of skaters did not have a heel brake on their skates. Use of PPE was influenced by group norms.

Conclusion: Personal protective equipment use is low among in-line skaters in Victoria, and varies according to skate location. The use of PPE in Victoria is much lower than that reported overseas.
Implications: Evidence of the effectiveness and the low use of PPE by skaters highlights the need to better promote the use of wrist guards, elbow and knee pads and helmets to skaters of all ages and abilities. There is opportunity for public health professionals to work in partnership with in-line skating bodies, organisers and sponsors of skating events, skate venue owners and managers, skating equipment manufacturers and hirers to promote PPE use.

INTRODUCTION
The frequency of in-line skating injury has increased with the rise in popularity of the sport (1). In Victoria, the number of injuries associated with in-line skating reported from hospital emergency department surveillance has increased markedly since 1989 (1, 2). In the US, there has been a 169% increase in emergency department injuries associated with in-line skating since 1993 (3). This trend in in-line skating injury has prompted the International In-line Skating Association, the American Medical Association and the US Consumer Product Safety Commission to strongly urge all in-line skaters to wear full personal protective equipment (PPE) - a helmet, wrist guards, knee and elbow pads (4-6).

PPE use has been shown to be effective in protecting skaters from upper limb injury (3), the most commonly reported anatomical site of injury (2, 7-9). Schieber et al. (1996) found that the odds ratio for wrist injury, adjusted for age and sex, for those who did not wear wrist guards, compared to those who did, was 10.4:1. The authors concluded from their calculations of population-attributable risk that the non-use of wrist guards accounted for 87% of all wrist injuries. The failure to use knee pads accounted for an estimated 32% of all knee injuries and failure to use elbow pads accounted for 82% of all elbow injuries (3). Small sample sizes precluded any definitive evaluation of the effectiveness of helmets, however, standards-approved bicycle helmets have been shown to reduce the risk of head injuries in cyclists (10). The use of PPE has also been associated with a decreased likelihood of hospitalisation in injured skaters (11).

Observational studies conducted in the US and Canada report that a significant proportion of in-line skaters wear no PPE (7-38%) (11-13). There are no reported observational studies of PPE use by in-line skaters in Australia, and no studies describing PPE use in different skate settings.

The aim of this observational study is to describe the use of PPE by in-line skaters at four different skate settings (rink, park, trail and 'street') in Melbourne and rural Victoria, and to compare local wearing rates with reported international rates.

METHODS
In the absence of Victorian in-line skating participation data, a combination of methods was used to select the local government areas (LGAs) in the study. Information on popular skating venues was obtained from the Victorian Yellow Pages Telephone Directory (rinks), local council recreation officers (skate trails, parks and informal sites) and in-line skating internet web-sites (skater recommended sites). Hospital Emergency Department presentations data for in-line skating injuries were available from 25 hospitals across Victoria (1) and these data were also consulted as an indicator of exposure. Six local government areas (cities of Brimbank; Greater Dandenong; Hume; Melbourne, Stonnington and Port Philip; Ballarat; and Latrobe) were selected to provide a geographical spread (from urban to rural) and include popular facilities for different styles of skating and age and skill levels of skaters within or close to their boundaries. The selected LGAs included high and low skater injury areas. The sample is also a cross-section of household income levels in Victoria from low to high (14).

Two trained observers made observations on weekends from mid-November 1998 to mid-January 1999. The same observer recorded identification and protective equipment data for each in-line skater in their line of vision for one hour at each of the four skate settings. Traditional roller skaters, speed skaters and skateboarders were excluded.

'Rinks' were indoor, privately owned venues. 'Parks' were outdoor skate facilities located in Council parks and included ramps, 1/2 pipes, bowls, and grind rails. 'Trails' were multi-use paved pathways, often located along waterways and separate from motor vehicle traffic. 'Street' included motor vehicle roadways, as well as footpaths, school grounds, and shopping pedestrian areas.

Identification data included sex, age group, ability, group size (number of skaters), hair colour, shirt colour and pants colour. Equipment data included presence of helmet, wrist guards, knee and elbow pads, and skate heel brake. Skaters were subjectively divided into five age groups ( 9 years, 10-14 years, 15-19 years, 20-34 years and 35 years) and three skill levels (novice, average and expert), as previously described (13).

All raw data was recorded on an optical mark reading data entry form and data entry was via laser scanning. Skaters observed on the same day with identical descriptive characteristics and protective equipment were assumed to be duplicates and excluded. Data comparing PPE use by group size were analysed using chi-square methods.

RESULTS
490 in-line skaters were observed at 24 sites in six local government areas. Most skaters were male (54.7%) and aged 14 years (57.6%). As age increased, the proportion of observed skaters decreased, from 33.3% aged 9 years to 4.5% aged 35 years (Figure 1).

The majority of skaters were observed on rinks (61.2%) and on trails (22.7%) (Figure 1). Fewer skaters were seen in parks (9.4%) and on the street (6.7%). Just over one half of the skaters were classified as average (51.4%), 32.2% as novice and 14.3% as expert. Skaters mostly skated alone (37.3%) or in pairs (31.4%).

A different age pattern was observed in the four settings. Younger skaters predominated on rinks (49.0% aged 9 years), adolescents at parks (55.6% aged 15-19 years) and older skaters on trails (53.2% aged 20-34 years)(Figure 1).

Figure 1 - Age distribution of observed in-line skaters

Personal Protective Equipment Use

Overall
Two-thirds of skaters (66.7%) wore no PPE (Figure 2). Only 11 skaters (2.2%) were observed wearing all four recommended pieces of PPE. Skaters wearing only one item mostly wore wrist guards (64.6%) or knee pads (33.8%). Skaters wearing two items mostly wore a combination of wrist guards and knee pads (85.2%).

Figure 2 - Number of personal protective equipment items worn by in-line skaters

The most frequently worn items were wrist guards (25.9%) and knee pads (23.5%)(Figure 3). Few skaters wore elbow pads (6.9%) and helmets (5.5%). Almost one-third of skaters (31.6%) did not have a heel brake on their skates.

Figure 3 - Personal protective and other safety equipment used by in-line skaters

Comparison by sex
Overall, PPE wearing rates for male and female skaters were similar (M: 35.4%, F: 30.2%) (Figure 4). They were equally likely to wear wrist guards (M: 25.7%, F: 26.1%) and knee pads (M: 24.3%, F: 22.5%). Male skaters, however, were less likely than female skaters to wear elbow pads (M: 4.5%, F: 9.9%) and to have a heel brake on their skates (M: 55.6%, F: 83.8%). The infrequent use of helmets was a characteristic of both groups (M: 6.3%, F: 4.5%).

Figure 4 - Personal protective equipment use by sex

Comparison by age group
Overall, skaters aged 20-34 years were more likely to wear PPE than other age groups (Figure 5). Nearly three-quarters of skaters aged from 20 to 34 years (72.7%) wore at least one item of PPE, whereas younger skaters were less likely to wear any PPE ( 9 years, 19.0%; 10-14 years, 21.0%; 15-19 years, 38%).

Wrist guard (71.4%), knee pad (44.2%) and elbow pad (19.5%) use was highest among 20 to 34 year olds (Figure 5). Helmet use was generally low for all age groups. Heel brake presence was lowest in the 15-19 years age group (46.3%) and highest among 0-9 year olds (88.3%).

Figure 5 - Personal protective equipment use by age group

Comparison by skating ability
Novice (41.1%) and expert skaters (37.7%) were more likely to wear PPE than skaters of average ability (27.0%)(Figure 6). Novice skaters were also more likely to wear a helmet (9.5% novice; 7.1% expert; 2.4% average), wrist guards (34.8% novice; 21.8% average; 21.4% expert), and elbow pads (14.6% novice; 4.3% expert; 2.8% average). Expert and novice skaters were most likely to wear knee pads (31.4% expert; 31.0% novice; 16.7% average). The presence of a heel brake decreased as skating ability increased (91.1% novice; 69.0% average; 10.0% expert).

Figure 6 - Personal protective equipment use by skating ability level

Comparison by setting
Skaters observed on trails were most likely to wear PPE (83.8% trail; 45.5% street; 41.3% parks; 12.0% rinks) (Figure 7). Trail skaters were most likely to wear all PPE items except helmets. Helmet use was higher in skaters observed on the street (18.2%) and parks (15.2%), and lower in rinks (3.0%) and trails (4.5%). Wrist guard use was highest in skaters observed on trails (74.8% trail; 27.3% street; 13.0% park; 9.7% rink), as was elbow pad use (16.2% trail; 12.1% street; 3.7% rink; 2.2% park) and knee pad use (59.9% trail; 41.3% park; 39.4% street; 5.7% rink). Trail and rink skaters were much more likely to have heel brakes on their skates than were street and park skaters (78.4% trail; 77.7% rink; 30.3% street; 10.9% park).

Figure 7 - Personal protective equipment use by skating location

Comparison by group size
A comparison of the expected and observed use of PPE among groups of skaters suggests that group norms influence PPE use (Table 1). Skaters in groups were significantly more likely to wear the same pattern of PPE as their companions than would be expected if skaters were grouped randomly (P<0.05).

Table 1: Use of PPE within groups

DISCUSSION

Overseas studies have determined PPE use among in-line skaters by unobtrusive observation (11-13, 15) or unvalidated skater surveys (16-18). A higher rate of PPE use is consistently reported from the skater surveys. The observation method minimises self-report bias and was used in our study. However, limitations may include observer bias in age and skill classification and the low number of skaters observed in some settings. Also, selection bias may have been introduced in the choice of LGAs. Injury frequencies were consulted to give an indication of exposure and may bias our sample towards areas with lower wearing rates of PPE. However, 2 of the 6 LGAs chosen were areas of low injury frequency (yet highly popular with skaters) and the PPE wearing rates in these 2 areas were comparable to the wearing rates in areas of high injury frequency. Despite this consistency, the generalisability of the results is limited due to the method of sample selection.

Two-thirds of in-line skaters in our study (66.7%) wore no PPE. This is a much higher non-wearing rate than reported from US and Canadian observational studies (7.3-38.0%)(11-13) and skater surveys (27.5-29.1%)(16, 18).

We observed very few in-line skaters (2.2%) wearing all four recommended pieces of PPE (helmet, wrist guards, elbow and knee pads). Similar low usage rates have been reported from observational studies in the US (11, 19). By contrast, one survey found that 15% of in-line skaters self-report 'always wearing' all four recommended pieces of PPE (16).

The most popular item of PPE was wrist guards, worn by 25.9% of skaters. This finding has been reported from a number of US observational studies, but reported rates of wrist guard use are more than double those found in our study (60-65.2%) (11, 13, 15). Only one observational study of Canadian skaters has reported wrist guard use lower than in our study (16.3%) (12). Much higher rates of wrist guard use are reported from skater surveys (51.0-72.5%) (16-18).

Approximately one-quarter of skaters in our study wore knee pads (23.5%). Other observational studies report knee pad use ranging from 9.8 to 44.0% (11-13, 15), while skater surveys report knee pad use ranging from 30.5 to 41.0% (16-18).

We found only a small proportion of in-line skaters wearing elbow pads (6.9%) and helmets (5.5%). Other observational studies report elbow pad use ranging from 3 to 27.0% (11-13, 15) and helmet use less than 3.0% in the US (11, 13) and 12.2% in Canada (12). Surveys of in-line skaters report elbow pad use ranging from 15.0 to 26.0% (16, 17) and helmet use ranging from 15.0% (17) to as high as 43.6% (16).

Overseas studies consistently indicate that female skaters are more likely to wear PPE (12, 13, 16) and less likely to be injured (1, 8) or hospitalised (1) than male skaters. However, we found similar wearing rates of PPE in both sexes.

Overseas and local research indicates that children aged 10-14 years most often present to hospital emergency departments with in-line skating injuries (2, 7, 20, 21), averaging approximately 11 years (1, 7, 20). This study and one other (13) have found that younger skaters are the least likely age group to wear any PPE. A link between PPE use and the risk of injury is suggested, however other factors such as higher exposure and skater inexperience may also play a role.

Several studies indicate that the average skating experience at the time of injury is less than 6 months (2, 3, 7, 22), although more experienced skaters are also at risk (2). Previous studies have reported that more experienced skaters are less likely to wear PPE than novice skaters (13, 19). We found, however, that novice skaters were more likely than average and expert skaters to wear a helmet, wrist guards and elbow pads, and only slightly less likely than expert skaters to wear knee pads. In a few instances, expert skaters were observed wearing only one knee pad, on what appeared to be their dominant or exposed "trick" leg.

Previous studies report primarily on skaters seen on paved trails in lakefront parks. Ours is the first study to compare the use of PPE by in-line skaters in different skate settings. The overall non-wearing rate of PPE reported here (66.7%) is much higher than that reported previously (11-13, 18). When we confined our analysis to skaters observed on trails, we found that trail skaters were most likely to wear PPE, except helmets. The non-use of PPE by Victorian skaters on trails (16.7%) is less than that of US skaters (29.1-38%)(11, 13, 18) and higher than that of Canadian skaters (7.3% no PPE)(12). This analysis highlights the high non-wearing rate of PPE in settings other than trails.

The higher PPE use among trail skaters may be associated with the responsible behaviour of hire shops located near popular trails, where PPE (except helmets) are supplied free with hired skates. The disproportionate number of older skaters on trails may also contribute to the peak in wrist guard use observed in this setting. The greatest non-use of PPE was seen in rinks, which along with skate parks have good potential for the dissemination of safety information and the provision of PPE with skate hire.

These findings highlight the variation in the use of PPE in different skate settings and the importance of broadening PPE awareness campaigns to include skaters of all ages and types. The non-wearing rate of PPE is as high as 88% in some skate settings, much higher than previously estimated from overseas studies.

Many skaters have difficulty braking (2, 3, 13, 20), and our observation that 44.4% of male skaters and 16.2% of female skaters had no heel brake on their skates is a cause for concern. This is lower than reported from a skater survey in New York Central Park (56.5% did not use heel brake)(18) but much higher than observed in one Canadian study (14.5% of male skaters did not have a heel brake)(12). We found that the presence of a heel brake varied with age, location and ability. Younger skaters, skater on trail and rinks, and novice skaters were most likely to have a heel brake on their skates. No other studies have reported on these aspects.

Group norms appear to influence the use of PPE. Skaters observed in groups were significantly more likely to show the same pattern of PPE use than expected if skaters were grouped randomly. This finding is consistent with one US observational study (13). Reasons cited in the literature for skaters not wearing PPE are that it is perceived to be unnecessary, is uncomfortable, looks foolish, is inconvenient, is an added expense and peers do not approve (17, 19). Peer influence is also reported as a contributory factor for bicycle helmet use in primary school-aged children (23) and teenagers (24). Our findings suggest that if a selected group of role models can be convinced to wear PPE, their example may have an exponential positive effect among their peers.

Conclusion
Other countermeasures to prevent in-line skating related injury are considered in an earlier report (1), PPE use is our strongest recommendation. PPE use among in-line skaters in Victoria is much lower than PPE use reported from overseas studies. Only a very small proportion wear all recommended items of PPE (wrist guards, elbow and knee pads and helmets). Wrist guards are the most-used item. Younger skaters and skaters of average ability are least likely to wear any PPE. Skaters on trails are more likely to use PPE than skaters on rinks, parks and streets. A significant proportion of skaters had no heel brake fitted to their skates, especially male skaters in parks and on the street. Group norms appear to influence PPE use.

Public health professionals, in-line skating bodies and equipment manufacturers should promote the use of full PPE to skaters of all ages and abilities in all settings. Full PPE should be readily available and promoted at the point of skate purchase or rental, preferably as a 'package deal'. Lessons by certified skating instructors should be promoted and the importance of using PPE should be addressed during lessons. Manufacturers should improve the design of PPE to make it more comfortable to wear and more attractive to children and adolescents. Event organisers and sponsors should promote the wearing of PPE at major skating events, using skating champions as role models. Government should consider mandating the use of PPE on streets and council property and offer rebates to offset the cost of purchase (as used in Victoria to encourage bicycle helmet use).

Acknowledgements
The authors would like to thank Professor Joan Ozanne-Smith for advice and comments and Ms. Kirstan Corben for assistance in data collection. Funding of this study by the Ian Potter Foundation is gratefully acknowledged.

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