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 utilise of personal protective equipment (PPE) past 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 iv 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). But 2.two% wore all four pieces of PPE. Wrist guards were worn by 25.9% of skaters, knee pads by 23.5%, elbow pads past half-dozen.9% and helmets by 5.v%. Younger skaters were to the lowest degree likely to wear any PPE. Trail skaters were more likely to wear PPE than skaters on rinks, parks and streets. About one-tertiary of skaters did not have a heel brake on their skates. Utilise of PPE was influenced by group norms.

Determination: 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 past 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 piece of 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 employ.

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INTRODUCTION
The frequency of in-line skating injury has increased with the rise in popularity of the sport (one). In Victoria, the number of injuries associated with in-line skating reported from hospital emergency department surveillance has increased markedly since 1989 (i, two). In the US, there has been a 169% increase in emergency section 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 Production Safe Commission to strongly urge all in-line skaters to wearable full personal protective equipment (PPE) - a helmet, wrist guards, knee and elbow pads (four-6).

PPE utilize has been shown to be constructive in protecting skaters from upper limb injury (3), the well-nigh ordinarily reported anatomical site of injury (ii, vii-ix). Schieber et al. (1996) constitute that the odds ratio for wrist injury, adjusted for historic period and sex, for those who did not habiliment wrist guards, compared to those who did, was 10.four:1. The authors concluded from their calculations of population-attributable risk that the non-use of wrist guards deemed for 87% of all wrist injuries. The failure to use knee pads deemed for an estimated 32% of all knee joint injuries and failure to use elbow pads accounted for 82% of all elbow injuries (3). Small sample sizes precluded whatever definitive evaluation of the effectiveness of helmets, however, standards-approved cycle helmets take been shown to reduce the take a chance of caput injuries in cyclists (x). The use of PPE has also been associated with a decreased likelihood of hospitalisation in injured skaters (11).

Observational studies conducted in the U.s.a. and Canada report that a meaning proportion of in-line skaters wearable no PPE (7-38%) (11-13). There are no reported observational studies of PPE use past in-line skaters in Commonwealth of australia, and no studies describing PPE use in dissimilar skate settings.

The aim of this observational study is to describe the use of PPE by in-line skaters at four dissimilar 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 report. Information on pop skating venues was obtained from the Victorian Yellow Pages Telephone Directory (rinks), local quango recreation officers (skate trails, parks and informal sites) and in-line skating internet web-sites (skater recommended sites). Hospital Emergency Section presentations information for in-line skating injuries were available from 25 hospitals across Victoria (1) and these information were also consulted as an indicator of exposure. Six local authorities 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 pop facilities for unlike styles of skating and age and skill levels of skaters inside or close to their boundaries. The selected LGAs included high and low skater injury areas. The sample is too a cantankerous-section of household income levels in Victoria from low to high (14).

Two trained observers fabricated observations on weekends from mid-November 1998 to mid-January 1999. The aforementioned observer recorded identification and protective equipment information for each in-line skater in their line of vision for 1 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 Quango parks and included ramps, 1/2 pipes, bowls, and grind rail. 'Trails' were multi-use paved pathways, frequently located forth waterways and separate from motor vehicle traffic. 'Street' included motor vehicle roadways, besides equally 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, human knee and elbow pads, and skate heel restriction. Skaters were subjectively divided into 5 age groups ( ix years, ten-xiv years, xv-xix years, twenty-34 years and 35 years) and three skill levels (novice, average and good), as previously described (13).

All raw information 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 6 local authorities 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 nine years to four.5% anile 35 years (Effigy 1).

The bulk of skaters were observed on rinks (61.ii%) and on trails (22.seven%) (Figure 1). Fewer skaters were seen in parks (nine.four%) and on the street (six.vii%). But over ane half of the skaters were classified as average (51.4%), 32.2% as novice and fourteen.3% equally expert. Skaters mostly skated alone (37.iii%) or in pairs (31.4%).

A dissimilar historic period pattern was observed in the four settings. Younger skaters predominated on rinks (49.0% aged 9 years), adolescents at parks (55.6% aged xv-nineteen years) and older skaters on trails (53.2% aged 20-34 years)(Figure ane).

Figure 1 - Age distribution of observed in-line skaters

Personal Protective Equipment Utilise

Overall
2-thirds of skaters (66.vii%) wore no PPE (Effigy 2). Only 11 skaters (two.2%) were observed wearing all four recommended pieces of PPE. Skaters wearing just one item mostly wore wrist guards (64.6%) or knee joint pads (33.8%). Skaters wearing 2 items mostly wore a combination of wrist guards and articulatio genus 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 human knee pads (23.5%)(Figure 3). Few skaters wore elbow pads (6.9%) and helmets (5.five%). Almost ane-tertiary of skaters (31.six%) did not take a heel restriction 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 wearable wrist guards (M: 25.7%, F: 26.1%) and human knee pads (M: 24.iii%, F: 22.5%). Male skaters, however, were less likely than female person skaters to wear elbow pads (M: four.5%, F: 9.nine%) and to accept a heel brake on their skates (1000: 55.6%, F: 83.8%). The infrequent use of helmets was a characteristic of both groups (Grand: 6.3%, F: 4.5%).

Figure 4 - Personal protective equipment apply by sex

Comparison by age grouping
Overall, skaters aged xx-34 years were more likely to wear PPE than other historic period groups (Figure v). Nearly three-quarters of skaters aged from 20 to 34 years (72.7%) wore at to the lowest degree one item of PPE, whereas younger skaters were less likely to wear any PPE ( 9 years, 19.0%; 10-14 years, 21.0%; fifteen-xix years, 38%).

Wrist guard (71.four%), knee joint pad (44.ii%) and elbow pad (19.five%) use was highest among 20 to 34 year olds (Figure five). Helmet utilize was more often than not depression for all historic period groups. Heel brake presence was lowest in the 15-19 years age group (46.3%) and highest amongst 0-9 year olds (88.3%).

Figure 5 - Personal protective equipment use by historic period grouping

Comparison by skating ability
Novice (41.1%) and expert skaters (37.7%) were more likely to article of clothing PPE than skaters of average ability (27.0%)(Figure 6). Novice skaters were also more likely to wear a helmet (9.v% novice; 7.one% adept; 2.iv% average), wrist guards (34.8% novice; 21.eight% average; 21.4% practiced), and elbow pads (14.6% novice; 4.3% expert; two.viii% average). Expert and novice skaters were most likely to clothing knee pads (31.four% expert; 31.0% novice; 16.seven% average). The presence of a heel brake decreased every bit skating ability increased (91.1% novice; 69.0% boilerplate; 10.0% expert).

Figure six - Personal protective equipment use by skating ability level

Comparison by setting
Skaters observed on trails were near likely to article of clothing PPE (83.8% trail; 45.v% street; 41.3% parks; 12.0% rinks) (Effigy 7). Trail skaters were most likely to wear all PPE items except helmets. Helmet employ was higher in skaters observed on the street (18.2%) and parks (15.2%), and lower in rinks (3.0%) and trails (4.five%). Wrist guard employ was highest in skaters observed on trails (74.8% trail; 27.3% street; 13.0% park; 9.7% rink), as was elbow pad utilize (16.2% trail; 12.1% street; 3.7% rink; ii.two% park) and genu pad utilize (59.ix% trail; 41.3% park; 39.four% street; 5.7% rink). Trail and rink skaters were much more than likely to have heel brakes on their skates than were street and park skaters (78.iv% trail; 77.seven% rink; xxx.3% street; ten.ix% park).

Figure 7 - Personal protective equipment use by skating location

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

Table i: Use of PPE within groups

	Observed use of PPE n (%)	Expected use of PPE a northward (%)
Groups of ii skaters (north=76)
Both with no PPE	38 (fifty.0%)	23 (30.3%)
Both with some PPE	31 (40.8%)	fifteen (xix.7%)
Mixed group (one with PPE, 1 without)	7 (9.2%)	38 (fifty.0%)
Groups of three skaters (n=26)
All with no PPE	sixteen (61.five%)	8 (thirty.8%)
All with some PPE	v (19.2%)	1 (iii.8%)
Mixed group (with and without PPE)	v (19.2%)	17 (65.4%)

DISCUSSION

Overseas studies have determined PPE use among in-line skaters by unobtrusive ascertainment (xi-13, 15) or unvalidated skater surveys (16-18). A higher rate of PPE apply is consistently reported from the skater surveys. The observation method minimises cocky-report bias and was used in our study. Nonetheless, limitations may include observer bias in historic period and skill classification and the low number of skaters observed in some settings. Also, pick bias may take been introduced in the pick 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, two of the vi 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 express due to the method of sample selection.

Ii-thirds of in-line skaters in our report (66.vii%) wore no PPE. This is a much higher not-wearing rate than reported from United states of america and Canadian observational studies (7.3-38.0%)(11-13) and skater surveys (27.5-29.ane%)(16, xviii).

We observed very few in-line skaters (two.2%) wearing all 4 recommended pieces of PPE (helmet, wrist guards, elbow and knee pads). Like low usage rates have been reported from observational studies in the US (eleven, xix). By contrast, one survey found that 15% of in-line skaters self-study 'always wearing' all four recommended pieces of PPE (16).

The most pop item of PPE was wrist guards, worn by 25.9% of skaters. This finding has been reported from a number of The states observational studies, only reported rates of wrist guard use are more than double those found in our study (sixty-65.2%) (11, 13, fifteen). Just i observational study of Canadian skaters has reported wrist guard use lower than in our study (16.3%) (12). Much higher rates of wrist baby-sit employ are reported from skater surveys (51.0-72.5%) (16-18).

Approximately one-quarter of skaters in our written report wore knee pads (23.v%). Other observational studies report knee joint pad use ranging from nine.8 to 44.0% (eleven-13, xv), while skater surveys report knee pad use ranging from thirty.5 to 41.0% (16-18).

Nosotros found simply a pocket-sized proportion of in-line skaters wearing elbow pads (6.nine%) and helmets (5.v%). Other observational studies report elbow pad employ ranging from 3 to 27.0% (xi-13, fifteen) and helmet employ less than 3.0% in the US (eleven, xiii) and 12.2% in Canada (12). Surveys of in-line skaters written report elbow pad use ranging from 15.0 to 26.0% (16, 17) and helmet use ranging from fifteen.0% (17) to as high as 43.six% (16).

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

Overseas and local enquiry indicates that children anile 10-14 years most oft present to hospital emergency departments with in-line skating injuries (2, vii, twenty, 21), averaging approximately 11 years (1, 7, xx). This study and one other (xiii) accept establish that younger skaters are the to the lowest degree probable age group to wear any PPE. A link betwixt PPE use and the hazard of injury is suggested, withal other factors such as college exposure and skater inexperience may also play a office.

Several studies signal that the average skating feel at the fourth dimension of injury is less than 6 months (2, iii, 7, 22), although more experienced skaters are also at take a chance (two). Previous studies have reported that more experienced skaters are less probable to clothing PPE than novice skaters (13, xix). We found, however, that novice skaters were more likely than boilerplate and expert skaters to wear a helmet, wrist guards and elbow pads, and only slightly less likely than skilful skaters to wear knee pads. In a few instances, skilful skaters were observed wearing simply 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 unlike skate settings. The overall not-wearing rate of PPE reported here (66.7%) is much higher than that reported previously (eleven-13, 18). When we confined our assay to skaters observed on trails, we found that trail skaters were near likely to wear PPE, except helmets. The not-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 not-wearing charge per unit of PPE in settings other than trails.

The college PPE use amidst trail skaters may exist associated with the responsible behaviour of hire shops located near pop trails, where PPE (except helmets) are supplied free with hired skates. The disproportionate number of older skaters on trails may also contribute to the top in wrist baby-sit utilise observed in this setting. The greatest non-utilise of PPE was seen in rinks, which forth with skate parks take practiced potential for the broadcasting of safety data and the provision of PPE with skate hire.

These findings highlight the variation in the use of PPE in dissimilar 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 every bit high as 88% in some skate settings, much higher than previously estimated from overseas studies.

Many skaters have difficulty braking (2, 3, thirteen, 20), and our observation that 44.4% of male person skaters and 16.2% of female person 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 Fundamental Park (56.v% did not use heel brake)(18) only much higher than observed in one Canadian study (xiv.five% of male person skaters did not take a heel restriction)(12). We constitute that the presence of a heel brake varied with age, location and ability. Younger skaters, skater on trail and rinks, and novice skaters were well-nigh probable to have a heel brake on their skates. No other studies have reported on these aspects.

Group norms appear to influence the utilize of PPE. Skaters observed in groups were significantly more probable to evidence the same pattern of PPE use than expected if skaters were grouped randomly. This finding is consistent with one U.s.a. observational study (13). Reasons cited in the literature for skaters not wearing PPE are that it is perceived to exist unnecessary, is uncomfortable, looks foolish, is inconvenient, is an added expense and peers do non corroborate (17, xix). Peer influence is also reported every bit a contributory gene for bike helmet apply in primary school-anile children (23) and teenagers (24). Our findings suggest that if a selected group of function models can be convinced to wear PPE, their example may have an exponential positive effect among their peers.

Conclusion
Other countermeasures to foreclose in-line skating related injury are considered in an before report (ane), PPE utilize is our strongest recommendation. PPE utilise 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 power are least likely to habiliment whatsoever 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 person skaters in parks and on the street. Grouping norms announced to influence PPE apply.

Public health professionals, in-line skating bodies and equipment manufacturers should promote the employ of full PPE to skaters of all ages and abilities in all settings. Total PPE should be readily available and promoted at the signal of skate purchase or rental, preferably as a 'bundle deal'. Lessons by certified skating instructors should be promoted and the importance of using PPE should be addressed during lessons. Manufacturers should better the design of PPE to make information technology more comfortable to wear and more bonny to children and adolescents. Event organisers and sponsors should promote the wearing of PPE at major skating events, using skating champions as function models. Government should consider mandating the use of PPE on streets and council property and offering rebates to commencement the cost of purchase (every bit used in Victoria to encourage cycle helmet use).

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

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