A pilot study of the attitudes of Australian Rules footballers towards protective headgear

~HORT REPORT(.

A pilot study of the attitudes of Australian Rules footballers towards protective headgear

CF Finch 1, AS Mcln tosh 2, P McCrory 3 & T Zazryn 1

1Department of Epidemiology and Preventive Medicine, Monash University, Victoria, Australia. 2School of Safety Science, University of New South Wales, New South Wales, Australia. 3Centre for Sports Medicine Research and Education and the Brain Research Institute, University of Melbourne,

victoria, Australia.

Finch, CF, McIntosh, AS, McCrory, P, & Zazryn, T (2003). A pilot study of the attitudes of Australian Rules footballers towards protective headgear. Journal of Science and Medicine in Sport 6 (4): 505-511.

Despite a relatively high risk of injury to participants of Australian Rules football, very few players report wearing protective equipment. The aim of this paper is to describe the results of a pilot survey of the attitudes of community-level Australian Rules football players towards protective headgear and the risk of head injury. Seventy players from four purposefully chosen clubs in metropolitan Melbourne completed a self-report questionnaire at the end of the 2000-playing season. Almost all players (91.4%) reported they did not wear protective headgear during the 2000 season. Non-headgear users said that headgear was too uncomfortable (47.4%) and they didn't like it (42.1%). However, 80.0% of non-users said they would wear it if it prevented injury. The major motivation for wearing headgear was to prevent injury. Players considered rugby, boxing and driving a car, to be associated with a higher- risk of head injury than Australian Rules football. As a group, the players perceived the risk of head injury in Australian Rules football to be low to moderate when compared to other sports and activities. This partially explains why so few players wore protective headgear. Repeat surveys on a larger sample should be conducted to further understand the attitudes towards protective headgear and perceptions of risk in community-level Australian football players.

Introduction The A u s t r a l i a n Foo tba l l League (AFL) g a m e is a p o p u l a r r e c r e a t i o n a l a n d compe t i t ive s p o r t i n g act ivi ty, e spec ia l ly in t he s o u t h e r n s t a t e s . A re la t ive ly h igh r i sk of i n j u r y for p a r t i c i p a n t s of th i s s p o r t a t t he c o m m u n i t y level h a s b e e n w e l l - d o c u m e n t e d I1,21. Unl ike s o m e o t h e r s p o r t s w h e r e t he u s e of p e r s o n a l p ro tec t ive e q u i p m e n t is well a c c e p t e d a n d even m a n d a t e d [a-Sl, i t is n o t ye t p a r t of t he c u l t u r e of t he AFL g a m e for p l a y e r s to u s e p ro tec t ive e q u i p m e n t extens ively . A l t h o u g h p ro tec t ive e q u i p m e n t h a s t he p o t e n t i a l to r e d u c e the f r equency a n d sever i ty of i n ju r i e s in footbal l Ill, few p l a y e r s u s e it. Fo r example , a r e c e n t s t u d y f o u n d t h a t b e t w e e n 6 4 % - 8 9 % of jun io r , sub -e l i t e a n d el i te- level AFL p l a y e r s wore m o u t h g u a r d s d u r i n g g a m e s I61.

The l ikely benef i t s of h e a d g e a r u s e b y A u s t r a l i a n footbal l p l a y e r s a re t he s u b j e c t of m u c h deba te , t h o u g h it h a s b e e n s u g g e s t e d b y s o m e t h a t i t cou ld p ro t ec t a g a i n s t mi ld T r a u m a t i c Bra in I n j u r y s u c h a s concus s ion , w h e r e a s o t h e r s c o n s i d e r i t m a y on ly have a role in p r e ve n t i ng the fo rehead , sca lp a n d

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A pilot study of the attitudes of Australian Rules footballers...

skull from injuries such as lacerat ions i71. Although the effectiveness of protective headgear for Austral ian football is yet to be demons t ra ted in formal trials, some players current ly choose to wear it. No s tudy has previously reported protective headgear wearing ra tes or at t i tudes towards the use of protective headgear by community-level AFL players.

For effective injury prevent ion strategies to be implemented it is necessary to unders tand the safety at t i tudes and beliefs of the individuals who will ult imately be us ing the equ ipment 18i. Atti tudes towards safety are shaped by previous experiences, as well as individual personalit ies, intentions, aspir- a t ions and expec ta t ions isi. The a t t i tudes and beliefs a b o u t protect ive equipment have been shown previously to influence the use of tha t equipment in work envi ronments I81, as well as with helmet use by cyclists I91 and protective eyewear in squash [1°1. The at t i tudes of spor ts par t ic ipants towards protective equipment can also be potential barr iers to its use and these barr iers need to inform the design and implementa t ion of strategies to increase usage rates. Another impor tan t aspec t is tha t of r isk perception, as improvements in safety can only be achieved when people perceive tha t a r isk is appa ren t and choose to remove or limit tha t r isk iSl. This pape r describes the findings of a pilot survey to determine the a t t i tudes of community- level AFL players towards protective headgear. This s tudy was unde r t aken as a p recursor to the design of a large scale randomised controlled trial of the effectiveness of such protective equipment for preventing injury (the Austra l ian Football Injury Prevention Project (AFIPP)).

Methods Seventy players from four purpose ly chosen clubs in metropol i tan Melbourne were surveyed at the end of the 2000-playing season. All players who were at tending training on the night of the survey were invited to part ic ipate and all players chose to do so. Players completed a self-report quest ionnaire during a supervised training session a t their football club.

The survey consisted of closed-ended questions, including 5-point Likert scales (ranging from strongly agree to strongly disagree or always to never). In fo rmat ion collected included: d e m o g r a p h i c details; p laying habi t s ; h e a d / f a c e / n e c k injury history in the previous twelve months , as defined by requiring medical t r ea tment or caus ing a game or training session to be missed; cur ren t use of protective headgear; and at t i tudes towards protective headgear: Quest ions used to ascer ta in the two mos t impor tan t reasons why players d id /d id not use protective headgear gave a list of options to tick (as shown in Table 1). Although no specific definition of h e a d / n e c k / f a c i a l / d e n t a l injury was given on the survey , players were given a set of examples including concussion, cuts to the cheek, chipped teeth and muscle strains.

All da ta were double entered into SPSS version 11.0. Approval for the project was obtained from the Deakin University Ethics Committee. Completion of the survey was unde r t aken to indicate informed consent for senior players (aged 18 years and over). Written informed consent was obtained from the paren ts or guard ians of junior players.

Results The surveyed players came from three senior t eams (n=55, average age: 24.9 years; range 17.6-51.1 years) and one junior t e am (n=15, average age: 15.8

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years; range 14.9-16.5 years). Over one-third of the surveyed players (38.6%, n=27) reported sustaining at least one injury to the head / face /neck ; six of these were to junior players. Four senior players reported two h ead /n eck / f ace injuries. Concussion was the most common head injury, accounting for two- thirds of cases. Nine players reported sustaining an injury to the face, two players reported dental injuries and three players sustained neck injuries.

Almost all players (91.4%) reported that they did not wear protective headgear during the 2000 season. Two players did not report headgear- wearing status. Amongst the four players who did wear headgear, two said they did not want to get an injury; both reported sustaining a h e a d / f a c e / n e c k injury in the previous 12 months. Three headgear-users said that they had experienced difficulty speaking while using the headgear, and one said his head felt uncomfortable. One player reported a restriction of play as well as peripheral vision impairment and taking more risks when wearing headgear. Three of the headgear users believed that headgear can often~sometimes prevent football injury.

The 64 players who reported not wearing protective headgear were asked to provide two reasons from a list of options for this (Figure 1). Major factors in their choice not to wear it were a belief tha t it was too uncomfortable, not liking it, and believing that they did not need it. Only 4 players said they would stop playing football if protective headgear was made compulsory. Four-fifths of non-users said they would wear protective headgear if they had an injury, and a fur ther 36.4% said they would wear it if it prevented injury (Table 1). It would appear that neither peer-influences nor the appearance of headgear strongly influence players to wear it.

All part icipants were asked to rate their perception of head injury risk in relation to the use of protective headgear. Most players agreed (40.0%) that protective headgear-users are less likely to be injured than those who don't wear it, a l though a third (35.7%) were unsure if headgear prevented injury. A majority of part icipants (42.9%) reported being unsu re if wearing headgear would be detrimental to their play, bu t 32.8% believed that their play would be adversely affected.

Influences on headgear usage % players

If I had an injury 80.0 If the equipment prevented injury 36.4 If I was made to by my school/club 21.8 If I wanted to be safe 20.0 If the equipment made me play better 12.7 If I was made to by my parents/coach 7.3 If it looked good 5.5 If my insurance company required me to wear it 5.5 If my team mates wore it 3.6 If it was compulsory 1.8

* 7 missing (4 not applicable as headgear-users)

Table 1: Potential motivators toward headgear use in current non-users (n=55 players)*.

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A pilot Stud~/of the attitudes of Australian Rules footballers...

Headgear affects my peripheral vision

I haven't had concussion

Headgear restricts my performance

Headgear doesn't work

'~" I don't want to look ~ stupid

It is too hot when wearing headgear

I have never considered/ tried headgear

There is no rule making me wear headgear

I don't need to wear headgear

~. I don't like wearing headgear

Wearing headgear is too uncomfortable

[ ]

5 10 15 20 25 30 35 40 45 50

Proportion of all players (%)

Figure 1: Reasons reported by players for not wearing protective headgear (n =57 players, 9 missing values).

Most players (75.4%) did not believe tha t headgear users could play harder than non-wearers and experience was not generally considered to be a factor against use of headgear (76.2%). One-quar te r (25.7%) of players indicated tha t they would ra ther r isk injury t h a n wear headgear. When asked if they would consider wearing headgear for an entire season, only 16.3% of players said they would and a lmost one-third (30.2%) were unsure .

RiSk of sustaining a head injury in each of the following situations

Proportion Proportion Proportion Proportion reporting reporting reporting reporting

no risk low riSk moderate risk high risk

Riding a bicycle on the road 2.9 17.1 32.9 47.1 Horse riding 2.9 14.5 34.8 47.8 Driving a car 10.1 39.1 24.6 26.1 Playing football 5.7 42.9 37.1 14.3 In-line skating/rollerblading* 0.04 6.7 40.0 13.3 Boxing 2.9 2.9 18.6 75.7 Playing rugby 2.9 4.3 32.9 60.0 BMX riding* 0.0 21.4 50.0 28.6 Skateboarding* 0.0 40.0 53.3 6.7 Drinking and driving ̂ 5.6 7.4 16.7 70.4

* This situation only asked of junior players ^ This situation only asked of senior players

Table 2: Perceived risk of sustaining a head injury in a variety of situations (n=70 players).

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In general, there was more support for junior players (aged under 18 years) to wear headgear than for senior players. Over 30% of senior players thought tha t headgear should be worn by junior players during games, and 11.4% indicated this for training. In contrast, 13.3% of junior players thought they should wear headgear during games, and even fewer (6.7%) for training.

The majority of players (80.0%) considered that playing football was associated with only a low to moderate risk of head injury (Table 2). In contrast, boxing and rugby were reported as having a high risk of head injury. In-line skating or roller-blading was considered to have the same level of high head injury risk as football. Almost double the number of players thought that driving a car was associated with a high head injury risk compared to football.

DiScussion Protective equipment has been widely adopted as a useful sports injury prevention strategy in some sports Ia-51. In order to increase acceptance and actual use of protective equipment, the factors associated with its use need to be unders tood lsl. With regard to the use of protective headgear, few published studies have been conducted into at t i tudes of adults towards usage, with the majority of research concentrated on children or adolescents.

Although the pilot s tudy reported here is based on only a small number of teams and players, it provides some useful information about the use of protective headgear by community-level AFL players. Further, this s tudy documents, for the first time, the at t i tudes of community-level AFL players towards protective headgear.

There is current ly little evidence that protective headgear is an effective injury prevention measure in Australian football and none of the available headgear is actually designed for the specific demands of this sport. However, in the absence of this information, some players current ly choose to wear headgear whereas others don't. It is important to unders tand reasons for both types of safety/r isk behaviours for injury prevention purposes. Players who mistakenly wear headgear because they think they are protected may place themselves at increased risk of injury. Future strategies to encourage protective equipment also need to unders tand what motivates people to wear or not wear it.

Use of protective headgear in this s tudy was low, and for two of the four players who did use it, not wanting to get an injury was the reason for doing so. However, both players had a prior history of head injury. This suggests that direct knowledge or experience of a head injury or head injury risk may be a predictor of protective equipment use, al though a larger sample would be required to confirm this. These factors have also been found to influence protective eyewear usage in squash ll°l and work-related injury i81. As such, education programs that inform players of the risk of head injury in football may influence headgear-wearing rates.

While over one-third of players had reported a previous head injury, as a group they perceived the risk of head injury to be low to moderate, compared to other sports. In general, the sports of boxing and rugby were considered to have a higher risk of head injury than football. Although an analysis of Austral ian emergency depar tment presentat ions found Austral ian Rules football to be associated with a higher frequency of head injury than rugby

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(21.6% AFL injuries versus 7.8% for rugby injuries) Illl, the community-level AFL players surveyed considered rugby to have a higher r isk of head injury. However, the emergency depa r tmen t da ta were not exposure adjusted and therefore the actual r isk of head injury in AFL and rugby may differ. Almost half of the players rated the risk of head injury in football as none or low, a rating comparable to tha t of driving a car or inline skat ing/rol ler-blading. Interestingly, players considered driving a car to have a higher head- in jury r isk than playing football.

Amongst non-headgear wearers , one in five would consider wearing headgear if it was proven tha t it could prevent injury. However, a larger n u m b e r would wear it only if they had already sus ta ined a head injury. This is likely to be directly related to the perceived low risk of head injury in this group of football players. If the players do not believe tha t a r isk is apparent , they will also not believe tha t protect ion against the r isk is necessary. Whilst some players were uncer ta in abou t the efficacy of protective headgear, mos t still associated its use with a lower r isk of injury. Despite the very low headgear-wear ing rate, it is encouraging tha t only a few players reported tha t they would stop playing the AFL game if headgear was made compulsory.

Previous research has shown tha t a n u m b e r of factors influence people 's perceived r isk of injury [81. Factors believed to be associated with a lower perceived r isk include voluntary exposure to the risk; familiarity with the risk; hazards tha t are considered by individuals to have non-ca tas t rophic outcomes; hazards tha t are unders tood, known, controllable and preventable; and those tha t are consequent ia l ISl. It is possible, therefore, tha t given a large proport ion of these players have been playing football for a n u m b e r of years, their perceived injury r isk m a y be lower t han expected because they actively choose to part icipate in this spor t with its a t t endan t risks. The players may also not have such detailed knowledge of the actual r isks associated with the other sports and activities listed and, as such, perceive them to have a higher r isk of head injury.

Barriers to the use of protective headgear included, among others, tha t it was uncomfortable, too hot, it restricted per formance and per ipheral vision and that players did not wan t to look stupid. This information is impor tan t as it provides guidance for the development of protective headgear and future strategies to increase usage. Changes to the design of headgear may overcome the ba r r i e r s of discomfort , overhea t ing and res t r ic t ion of vision and performance, and therefore m a y increase the use of headgear in football. It should be noted however, tha t players were not asked if they had ever tried headgear, and as such the barr iers reported m a y be perceived ra ther t han actual barr iers to the use of headgear.

This pilot s tudy has provided the first da ta on at t i tudes of Austral ian football players to protective headgear. Head injury in this pilot s tudy was broadly defined and we acknowledge tha t a t t i tudes related to the efficacy of headgear are likely to vary dependent on such a definition. It is r ecommended tha t this survey is repeated on a larger sample to verify tha t these a t t i tudes are consis tent across playing levels and different leagues. Future research should a im to under s t and fur ther the a t t i tudes of players towards, and what in- f luences the use of, protective headgear, as well as documen t players ' percept ions of r isk of injury d u n n g part icipat ion in the spor t of football.

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Correlat ions of these percept ions of r isk with actual head injuries in prospective studies will also help to determine whether or not such at t i tudes and r isk percept ions are also risk factor for injury.

Acknowledgements This s tudy was funded by a research grant from the Victorian Health Promotion Foundation. The contr ibut ions of Annette daCosta and David Parkin to this s tudy are gratefully acknowledged.

References 1. Gabbe, B. and C. Finch, Injury countermeasures in Austral ian Football. J Sci Med Sport, 2000. 3(2 (June Supplement)): 31-40. 2. Stevenson, M., et al., Sport, age, and sex specific incidence of sports injuries in Western Australia. Br J Sports Med, 2000. 34: 188-194. 3. R6gnier, G., C. Sicard, and C. Goulet, Economic impact of a regulation imposing full-face protectors on adul t recreational hockey players. International Journal of Consumer Safety, 1995. 2(4): 191-207. 4. Torg, J., et al., The nat ional football head and neck injury registry. Report and conclusions 1978. Journal o f the American Medical Association, 1979. 241: 1477-1479. 5. Vinger, P., Sport eye injuries: a preventable disease. American Academy of Ophthalmology, 1981.88: 102-112. 6. Banky, J. and P. McCrory, Mouthguard use in Austral ian Football. J Scie Med Sport, 1999. 2(1): 20-29. 7. National Health and Medical Research Council, Head and neck injuries in football, in Guidelines for prevention and management. 1995, Austra l ian Government Publishing Service: Canberra. 8. Geller, E., Sensation, perception and percieved risk, in The psychology o f safety. How to improve behaviours and atti tudes on the job. 1998, CRC Press LLC: Florida. p.52-68. 9. Finch, C., Teenager 's at t i tudes towards bicycle helmets three years after the introduction of mandatory wearing. Inj Prey, 1996. 2: 126-130. 10. Eime, R.M., et al., Are squash players protecting their eyes? Inj Prey, 2002. 8: 239-241. 11. Finch, C., G. Valuri, and J. Ozanne-Smith, Sport and active recreation injuries in Australia: evidence from emergency depar tment presentat ions. Br J Sports Med , 1998. 32: 220-225.

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A pilot study of the attitudes of Australian Rules footballers towards protective headgear