The Effect of a Ski-Snowboard Injury Prevention Video on Safety Knowledge and Behaviours in School Programs

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2018-01-11 The effect of a ski-snowboard injury prevention video on safety knowledge and behaviours in school programs

Mitra, Tatum

Mitra, T. (2018). The effect of a ski-snowboard injury prevention video on safety knowledge and behaviours in school programs (Unpublished master's thesis). University of Calgary, Calgary, AB. http://hdl.handle.net/1880/106304 master thesis

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The effect of a ski-snowboard injury prevention video on safety knowledge and behaviours in

school programs

Tatum Priyambada Mitra

A THESIS

SUBMITTED TO THE FACULTY OF GRADUATE STUDIES

IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE

DEGREE OF MASTER OF SCIENCE

GRADUATE PROGRAM IN KINESIOLOGY

CALGARY, ALBERTA

JANUARY 2018

Purpose: To implement and evaluate the effects of a skiing and snowboarding injury prevention video on child and adolescent safety knowledge and behaviours.

Study Design: Cluster-randomized controlled trial.

Background: Skiing and snowboarding are two popular winter activities; however, these sports can lead to injury. Previous studies have found that injuries in snow sports can be prevented and may be associated with poor decisions, actions and human error. Currently, there is no comprehensive injury prevention program found in skiing and snowboarding.

Methods: The participants were students in grades 2 through 9 who were a part of the ski and snowboard school programs at a ski area in Southern Alberta. The participants were randomized into either the control or intervention group, based on the school they attended. The control group followed the current standard protocol for the ski and snowboard school programs, including an orientation video, while the intervention group received a video that focuses on safety knowledge and injury prevention. The outcomes were measured through the use of pre- and post-tests (safety knowledge uptake) and the observations of risky behaviours on the ski hill.

Results: There was a significant increase in safety knowledge scores for those in the intervention group immediately following exposure to the video intervention (mean change: +1.91 points/15 points) compared with the control group after exposure to the control video (mean change: +0.10 points/15 points). There were 23.31 risky behaviours/100 runs (95% CI: 16.75-29.87) for those in the control group, and 22.95 risky behaviours/100 runs (95% CI: 17.63-28.26) for those in the intervention group.

Conclusion: This project demonstrates that a skiing and snowboarding injury prevention video can improve knowledge scores within a school-aged population. The video intervention, however, was not associated with the overall incidence of risky behaviours in this population.

Future injury prevention research should investigate how to better translate knowledge to induce behavioural changes and limit risky behaviours in child and adolescent skiers and snowboarders.

iii ACKNOWLEDGEMENTS

The last two years have been full of obstacles and I have been so fortunate to have a myriad of people supporting and helping me over this time. Thank you to all the people that have been there throughout my masters and played any role in my success over my time as a masters’ student. First and foremost, I would like to express my sincere gratitude to my supervisors, Dr. Brent Hagel and Dr. Carolyn Emery, for all their guidance, patience, encouragement, and support throughout my entire project. I will be forever grateful to them for taking me under their wing and I am honoured that I have had the opportunity to work alongside such extraordinary individuals who are the top of their fields. I know the skills I have gained and the lessons I have learned through this entire process will be an asset in my future career goals. Dr. Emery and Dr. Hagel have provided me with exceptional opportunities and I have gained more than I possibly could have imagined from this master’s degree. Next, I would like to recognize and thank my committee members, Dr. Jeffery Caird, Dr. Kelly Russell, and Dr. Alberto Nettel-Aguirre. It was an absolute pleasure to work with all of them. I am extremely grateful for the wisdom, time, support and mentorship they have provided me over the years. They all played an integral role and their insight and feedback was invaluable throughout this process. I would especially like to thank Dr. Nettel-Aguirre, for always taking the time out of his day to give me impromptu statistics lessons and advice on life. Thank you to the research staff, coordinators, and students at the Sport Injury Prevention Research Centre who have been vital in helping me throughout my courses and project. This project could not have been completed without the incredible ski and snowboard team at SIPRC, the Alberta Children’s Hospital and Winsport, especially, Maya Djerboua, Dirk Chisholm, Sherry Mahmood, Hollie Cressy, Chris Lane, and Sebastian Staudt. I would also like to thank my incredible mentors Dr. Amanda Black, Dr. Sarah Kenny, Carla Van Den Berg, and Paul Eliason who have all been a wealth of knowledge whenever I have had questions. To my lab-mates and graduate students in the Faculty of Kinesiology, it’s been an absolute pleasure getting to know all of you. Thank you to all my friends for their support throughout my entire degree and always being there for me. To my CHS friends thank you all for making biostatistics, epidemiology and masters’ life survivable and helping me get through my degree. Finally, thank you to my family (Mom, Dad, Priya and Harpreet) for their unconditional love, support, and encouragement.

iv DEDICATION

This thesis is dedicated to my parents, Arundhati and Subrat Mitra, who have believed in me and supported me throughout my entire life, pushed me to chase my dreams, and taught me the importance of perseverance and hard work. And to my sister, Priya Mitra, who inspires me to always aim to be the best I can be. Thank you for all for the continued love and support and I honestly do not believe I would have been able to get to this point without you.

v TABLE OF CONTENTS

ABSTRACT ...... ii ACKNOWLEDGEMENTS ...... iv DEDICATION ...... v TABLE OF CONTENTS ...... vi LIST OF TABLES ...... x LIST OF FIGURES AND ILLUSTRATIONS ...... xii

CHAPTER ONE: INTRODUCTION ...... 1 1.1 Research Question ...... 3 1.2 Objectives ...... 3 1.3 Hypothesis ...... 3 1.4 Significance ...... 4 1.5 Summary of Thesis Structure ...... 4

CHAPTER TWO: LITERATURE REVIEW ...... 6 2.1 General Injury Risk in Youth ...... 6 2.1.1 Economic Burden of Skiing and Snowboarding Injuries ...... 6 2.1.2 Other Consequences of Injury ...... 7 2.2 Participation, Safety, and Injury Prevention in Skiing and Snowboarding ...... 8 2.2.1 Injury Prevention and Use of the Haddon Matrix in Skiing and Snowboarding ...... 9 2.2.2 Skiing and Snowboarding Injury Burden and Risk Factors ...... 12 2.3 The Role of Behaviour in Skiing and Snowboarding Injury Prevention ...... 14 2.3.1 Risky Behaviour in Sport Injury Prevention ...... 14 2.3.1.1 Assessment of Risk Taking and Risky Behaviours ...... 16 2.3.2 Factors Associated with Behavioural Changes ...... 17 2.3.2.1 Safety Equipment ...... 17 2.3.2.2 Previous Injury and Experiences ...... 18 2.3.2.3 Guidelines, Policies and Legislation ...... 19 2.3.2.4 Interventions ...... 21 2.4 The Role of Knowledge and Education in Skiing and Snowboarding Injury Prevention ...... 22 2.4.1 Associations between Behaviours and Knowledge ...... 22 2.4.2 Knowledge acquisition and uptake ...... 23 2.5 Educational Interventions to Reduce Injury Risk ...... 24 2.5.1 Lesson and Training Programs ...... 25 2.5.2 School-based Educational Interventions ...... 25 2.5.3 Video Interventions ...... 26 2.5.4 Development of Video Intervention for this Thesis Project ...... 28

CHAPTER THREE: VIDEO INTERVENTION AND KNOWLEDGE ...... 30 3.1 Introduction ...... 30 3.2 Methods ...... 32 3.2.1 Study Design ...... 32

vi 3.2.2 Participants ...... 32 3.2.3 Randomization ...... 32 3.2.4 Control Group ...... 33 3.2.5 Intervention Group ...... 33 3.2.6 Procedures ...... 33 3.2.7 Outcome measurements ...... 34 3.2.8 Analysis ...... 35 3.2.8.1 Sample size ...... 35 3.2.8.2 Analysis Plan ...... 35 3.3 Results ...... 37 3.4 Discussion ...... 47 3.5 Conclusion ...... 51

CHAPTER FOUR: BEHAVIOURAL TOOL DEVELOPMENT AND ASSESSMENT ...... 52 4.1 Introduction ...... 52 4.2 Methods ...... 53 4.2.1 Development of the Tool ...... 53 4.2.2 Determining Accuracy of the Tool ...... 54 4.2.2.1 Personnel Evaluating Video and Subjects ...... 54 4.2.2.2 Procedure for Evaluating Accuracy of the Tool ...... 54 4.2.3 Reliability of Observed Risky Behaviours on Ski Hill with Inter-Rater Assessment ...... 56 4.2.3.1 Participants ...... 56 4.2.3.2 Procedure for Evaluating Reliability Data ...... 57 4.2.4 Data Analysis ...... 58 4.2.4.1 Validation of the Form using Video Footage ...... 58 4.2.4.2 Observations of Risky Behaviour Inter-Rater Reliability ...... 59 4.3 Results ...... 59 4.3.1 Consensus using Video Footage ...... 59 4.3.2 Validation of the Form using Video Footage ...... 63 4.3.3 Observations of Risky Behaviour Inter-Rater Reliability ...... 66 4.4 Discussion ...... 69 4.5 Conclusion ...... 72

CHAPTER FIVE: RISKY BEHAVIOUR INCIDENCE RATES ...... 73 5.1 Introduction ...... 73 5.2 Methods ...... 74 5.2.1 Study Design ...... 74 5.2.2 Participants ...... 75 5.2.3 Randomization and Blinding Process ...... 75 5.2.4 Risky Behaviour and Actions Assessment Tool Development ...... 75 5.2.5 Observation Locations ...... 76 5.2.6 Rates of Risky Behaviours Viewed by Two Observers ...... 77 5.2.6.1 Procedure for observation days with Two Observers ...... 77 5.2.7 Rates of Risky Behaviours Viewed by a Single Observer ...... 78

vii 5.2.8 Data Storage ...... 79 5.2.9 Data Analysis ...... 79 5.2.9.1 Sample size for observations ...... 79 5.2.9.1 Rates of Risky Behaviours Viewed by Two Observers ...... 80 5.2.9.2 Rates of Risky Behaviours Viewed by a Single Observer ...... 80 5.3 Results ...... 81 5.3.1 Observations of risky behaviour by two observers ...... 82 5.3.2 Rates of Risky Behaviour by a Single Observer ...... 84 5.4 Discussion ...... 89 5.5 Conclusion ...... 93

CHAPTER SIX: CONCLUSIONS AND FUTURE DIRECTIONS ...... 94 6.1 Summary of Findings ...... 94 6.2 Strengths and Limitations ...... 96 6.2.1 Study Design ...... 96 6.2.2 Attrition ...... 97 6.2.3 Behavioural Assessment Form ...... 97 6.2.4 Generalizability ...... 98 6.2.5 Knowledge and Behaviour Outcome ...... 98 6.3 Future Directions, Recommendations and Conclusions ...... 99

REFERENCES ...... 101

APPENDICES ...... 122 Appendix A: Search Terms for Literature Review ...... 123 Appendix B: Letter from Winsport ...... 130 Appendix C: Video Intervention Development ...... 131 Appendix D: Ski and Snowboard Safety Video Script ...... 136 Appendix E: Cover Letter for Ethics ...... 148 Appendix F: Ethics Certificate/ Ethics Approval ...... 150 Appendix G: Consent Form ...... 152 Appendix H: Assent Form ...... 155 Appendix I: Invitation to Schools For Participant Recruitment ...... 157 Appendix J: Infographic Inviting Schools to Participate ...... 159 Appendix K: Invitation to Parents and Students for Participant Recruitment ...161 Appendix L: Infographic of Process Involved within Study for Schools ...... 162 Appendix M: Participant Recruitment Details ...... 164 N1. Participants: ...... 168 N2. Detailed Knowledge Procedure: ...... 169 N3. Detailed Behaviour Procedure: ...... 170 Appendix O: Pre and Post-Test Assessment for Student Participants ...... 172 Appendix P: Risky Behaviour and Actions Assessment Tool ...... 179 Appendix Q: Examples Of Video Clips ...... 181 Appendix R: Map for Locating Observing Sites At The Ski Area ...... 182 Appendix S: Sample Size Calculations ...... 184 S.1. Sample size: ...... 184

viii S.2. Knowledge: ...... 184 S.3. Risky Behaviour: ...... 194 S.3.1 Sample Calculation from proposal: ...... 194 Appendix T: Permissions to Use Copyrighted Materials ...... 199

ix LIST OF TABLES

Table 2-1. The Haddon matrix of ski and snowboard injuries ...... 10

Table 2-2. Potential Risk Factors for Injury in Skiing and Snowboarding ...... 13

Table 3-1. Characteristics of participating students in the control and intervention groups ...... 39

Table 3-2. Mean scores pre-, post- and 1-month post- tests for control and intervention groups ...... 40

Table 3-3. Proportion of students who answered each question correctly by test and intervention group ...... 42

Table 3-4. Characteristics of control and intervention group students completing the one- month post-test ...... 43

Table 3-6. Linear Regression of pre-test compared with immediate post-test change scores based on the effect of intervention status adjusted for other covariates and clustering by class...... 45

Table 3-7. Linear Regression of immediate post-test compared with 1-month post-test change scores based on the effect of intervention status adjusted by other covariates clustered by class ...... 46

Table 4-1. Breakdown of all risky behaviours identified in 100 video clips outlining the percent agreement, concordant and discordant pairs, and Kappa coefficient by the ski patroller and ski instructor ...... 61

Table 4-2. Consensus versus non-expert determination of risky behaviour identified within 100 video clips ...... 63

Table 5-1. Both versus at least one observer reported risky behaviour for inter-rater observations...... 83

x Table 5-2: Basic Descriptors: Sex, Activity, Proportions of Risky Behaviours, and Overall risky behaviour...... 84

Table 5-3. Number of Outcomes, Exposure, Rate and Rate Ratios By Each Covariate Category (Sex, Activity, Time Period, When Participants Watched The Video) ...... 86

Table S.1. Variations in sample size dependent on the variables ...... 193

xi LIST OF FIGURES AND ILLUSTRATIONS

Figure 2-1. An Accident and Injury Prevention model with emphasis on human, structural and cultural factors ...... 16

Figure 3-1. Flowchart of schools and participants involved within the study ...... 37

Figure 5-1. Flowchart of schools and participants involved within the study ...... 81

Figure C-1. Diagram of Health Action Process Approach (HAPA) Model ...... 135

Figure Q-1. Example of Video Clip ...... 181

Figure R-1. Trail map of Southern Ski Area ...... 182

Figure R-2. Observation Sites at Southern Alberta Ski Area ...... 183

xii 1

CHAPTER ONE: INTRODUCTION

Skiing and snowboarding are among the most popular winter activities in Canada. Recent data from the Canadian Ski Council indicates that there are approximately 2.5 million ski area visits in Alberta annually 1. In addition, there are approximately 78 million annual visits to ski hills across North America 2. These winter sports allow individuals to engage in healthy activities in nature and promote active lifestyles; however, with participation in sports such as skiing and snowboarding, there comes the risk of injury 2. Skiing and snowboarding make up approximately

18% of total sport and recreation related injuries 3. Previous literature shows that children and adolescents suffer a disproportionately larger number of injuries compared with other age groups

4–6.

School sanctioned ski and snowboard programs are important for promoting physical activity and provide an opportunity for young people to discover and engage in a potentially new activity or improve their current skills. However, because children are still developing mentally and physically, navigating high speed sports such as skiing and snowboarding may be difficult and increase the risk of injury7. Within the sport injury prevention literature, it is a common belief that preventing injuries from occurring in the first place can be done successfully through education and proper knowledge translation of safety behaviours 8–10; however, more evidence is needed to verify this 11. Public health advocates describe injury prevention strategies in terms of the 3 E’s: enforcement, engineering and education 10. Enforcement refers to re-enforcing safety regulations and sport policies; engineering refers to safety equipment design and safer environments used to play and practice; and education refers to increasing awareness of injury risk, best practices and encouraging the adoption of safer behaviours 10. Other literature states that there is already a decreased incidence of injury that can be attributed to correct protective

2 equipment use such as helmets and wrist guards 12,13. If children can be educated about strategies to safely engage in the sport, then they will likely carry these behaviours into adulthood while continuing to participate 14–18. It is in society’s best interest to find more effective ways to modify risky behaviours and prevent injuries. If successful, these changes could minimize risky behaviour, reduce injuries and subsequently healthcare costs and increase activity levels in the winter.

As participants of school sanctioned ski and snowboard programs, children and adolescents receive an introduction to the sport including basic safety information. Currently, there is no consistent, structured, and comprehensive injury prevention component built into the delivery of these ski and snowboard school outing programs. A pilot evaluation of an injury prevention program among junior high students skiing and snowboarding show promising results in preventing injury 19. Besides skiing and snowboarding, other sport programs (e.g. hockey) that have incorporated safety videos have been found them to be an effective means of increasing safety knowledge and inducing behavioural change that might lead to a reduction in injuries 20.

However, we are not aware of any comprehensive evaluations of a ski and snowboard injury prevention program currently in use. In addition, there is limited research that covers the effects of video interventions on knowledge uptake, behaviours and injury risk together in child and youth skiers and snowboarders engaged in school programs. This gap can potentially be bridged with the findings from our research project.

1.1 Research Question

Does a skiing and snowboarding injury prevention video viewed in preparation for school visits to a ski area result in increased knowledge and a reduction in risky behaviours in elementary and junior high school students?

1.2 Objectives

The overall study objective was to evaluate the effect of an injury prevention video intervention on improving knowledge and reducing risky behaviours in elementary and junior high school students who participated in ski and snowboard school programs at a ski area in

Southern Alberta.

The primary objective was to examine the change in scores on a knowledge questionnaire before and after elementary and junior high students watched the intervention or control video.

The secondary objective was to examine the accuracy and reliability of the tool used to assess risky behaviours among elementary students. A tertiary objective was to assess the incidence of risky behaviours on the hill and to evaluate any differences in risky behaviours students who watched the intervention and control group.

1.3 Hypothesis

The study hypothesis was that students in the video intervention group would demonstrate greater knowledge about ski and snowboard safety, protective equipment use and strategies to prevent injury. It was also expected that there would be a lower number of risky behaviours observed on the ski hill in the video intervention group compared with the control group.

1.4 Significance

By delivering injury prevention information and strategies through a ten-minute intervention safety video prior to the outing, there is potential to reduce risky behaviour and injury risk while encouraging physical activity. Evaluating the effectiveness of the video intervention in increasing injury prevention knowledge will aid in the development of safety protocols for school programs at other ski areas provincially and nationally. Another aspect of this project was to develop and evaluate the accuracy and reliability of a tool that could be used for assessing risky behaviours on the ski hill. Currently there is no tool we are aware of that can be used to reliably capture risky behaviours in skiing and snowboarding. The tool was also used to determine the incidence of risky behaviour seen within the ski and snowboard school program participants. Given the popularity of skiing and snowboarding, an intervention that could improve knowledge, instil safe behaviours and ultimately reduce injuries in youth skiing and snowboarding during the school program outing is important. Positive and safe initial experiences in skiing and snowboarding have the potential to increase future participation in these enjoyable winter activities.

1.5 Summary of Thesis Structure

This MSc thesis includes the investigation of the effectiveness of an injury prevention video intervention on safety knowledge and risky behaviours. Chapter 1 outlines the basic background information about skiing and snowboarding, the main research question, the objectives, the significance of the project and thesis format. Chapter 2 includes a comprehensive review of the literature on participation, risk of injury, a common injury prevention framework,

5 safety behaviour, safety knowledge, and known safety interventions in skiing and snowboarding. Chapter 3 focuses on the results of a cluster-randomized controlled trial evaluating changes in injury prevention knowledge before and after viewing the intervention or control video within school aged children in grades 2 through 9 (ages 6-14) participating in skiing and snowboarding school programs. Chapter 4 outlines the evaluation of the accuracy and reliability of the Risky Behaviours and Actions Assessment tool. Chapter 5 provides an overview of the findings from a comparison of the incidence of risky behaviours on the hill using the

Risky Behaviours and Actions Assessment tool between the intervention and control video groups. The final chapter summarizes the findings, details the strengths and limitations of the study, proposes future research directions, provides recommendations for improving skiing and snowboarding safety, and concludes the thesis.

CHAPTER TWO: LITERATURE REVIEW

2.1 General Injury Risk in Youth

Sports are popular worldwide given the known associated benefits of physical activity.

However, with participation in any sport, there is a chance of injury. Children and adolescents are regular participants in sporting activities 4,21,22. According to Statistics Canada, adolescents have been experiencing an increase in sport injury over the past decade, with those between the ages of 12 to 19 years having the highest proportion of sports injury (66% of all injuries were sport injuries); exceeding double that of working-age adults (29%) and seven times that of seniors (9%) 4,5. Sport injuries are regular occurrences seen in emergency departments (ED) and make up a majority of ailments for adolescents 23. Out of all injuries related to snow and ice activities, ski and snowboard injuries are second only to ice hockey injuries in terms of ED presentations 4,24. However, both skiing (12.6%) and snowboarding (11.3%) had higher rates of hospitalization when compared with ice hockey (3.6%) 24. Skiing and snowboarding injuries can have high economic and non-economic costs, especially for vulnerable populations (e.g., children and adolescents who are just learning). Therefore, it is important to consider the risk of injury within such sports and find adequate injury prevention strategies.

2.1.1 Economic Burden of Skiing and Snowboarding Injuries

Parachute reported that in 2010, unintentional injuries among Canadians resulted in 231

596 hospitalizations, 3 492 146 ED visits, 15 866 deaths and cost $26.8 billion 25. Injuries are the leading cause of death for Canadians under 45 years of age 25. The economic impact of injury goes well beyond the cost of a visit to the ED or family physician, as there are also a number of

7 associated direct and indirect costs 21. Direct costs of injury may include emergency medical services, charges for visiting physicians, hospital fees, imaging expenses (X-ray, CT, MRI), physical therapy, medication, and possible funeral expenses. Indirect costs can include lost wages, benefits, employers’ lost productivity, and administrative costs for processing insurance

21. The economic cost of a single severe ski or snowboard injury is estimated to range from

$10,000 to $28,000 (USD) 26–28. Previous research has shown that in many cases, a greater proportion of skiing and snowboarding injuries result in hospitalization compared with injuries in other sports 24.

2.1.2 Other Consequences of Injury

In addition to economic consequences, an injured individual can face multiple emotional and physical difficulties during their recovery, through the rehabilitation process and when returning to play. Pain29,30, loss of independence31, isolation32–34, anxiety 32–34, anger32–34, time lost participating in the desired activity and fear of re-injury 35–38 are a few among a long list of intangible non-monetary costs of injury. In some instances, children who have bad experiences will end up avoiding the activity or similar activities, potentially leading to a more sedentary lifestyle 39–41. It is well known that sedentary behaviours can have adverse effects on an individual’s health and can lead to chronic disease and illness 42. Comprehensive injury prevention approaches are needed within the sports of skiing and snowboarding to limit the individual and societal burden of injury risk.

2.2 Participation, Safety, and Injury Prevention in Skiing and Snowboarding

Skiing and snowboarding are two of the most popular winter activities with over 78 million annual visits to ski hills across North America 1,2. These fun-filled winter activities promote active lifestyles 1. Children and adolescents make up approximately 20% to 30% of all skiers and snowboarders in Canada2. Approximately 15% of Canadians over the age of 12 reported participating in alpine skiing, cross-country skiing or snowboarding at least once in the

2008-2009 season 1,2. Within Alberta, there are approximately 2.5 million ski area visits annually

In the United States, it is estimated that 77,300 skiing and 62,000 snowboarding injuries were treated in EDs during the 2002 ski season and that snowboarding is responsible for approximately 25% of non-fatal outdoor recreational injuries that require ED care 43,44. The fact that these activities commonly lead to injuries and hospitalizations indicates that injury prevention within skiing and snowboarding is extremely important 43,44. Due to the risk of injury in sports such as skiing and snowboarding 2, multiple prevention strategies such as helmet use, rules and guidelines for safe practices, formal lessons, and safety programs have been recommended 45. Canadian Paediatric Society safety recommendations for skiing and snowboarding include 45:

• Physicians should provide office-based anticipatory guidance and counselling before

families attempt the activity.

• Governments developed policy/legislation for mandatory helmet use by all ages while

skiing and snowboarding, with concurrent messaging to educate the public and resort

operators about the indisputable importance of helmets in saving lives and preventing

head injuries.

• Ski areas/resorts/parks should develop and enforce safety policies.

• Schools should develop policies mandating proper equipment use, formal instruction,

and appropriate supervision.

• Research should be supported to address interventions to increase safety equipment use,

information on participation rates, current prevalence and incidence of injuries, the roles

of preseason conditioning and training, and the evaluation of interventions to determine

their effectiveness and improve uptake.

* From Lynne J Warda, Natalie L Yanchar; Skiing and snowboarding injury prevention,

Paediatrics & Child Health, Volume 17, Issue 1, 1 January 2012, Page 35 45.

2.2.1 Injury Prevention and Use of the Haddon Matrix in Skiing and Snowboarding

One of the most common conceptual frameworks for injury prevention is the Haddon

Matrix, which covers how injuries occur and how to prevent them 46–48. The three rows within the

Haddon Matrix grid represent different phases of an injury (i.e., pre-event, event, post-event), while the columns of the Haddon Matrix represent different factors that can be influenced through intervention (i.e., host/individual, agent/vehicle, physical environment, social environment) 47,48. The Haddon Matrix is a tool that aids in generating strategies for preventing injury in an organized manner (See Figure 2.1 for the Haddon Matrix of ski and snowboard injuries) 47,48.

Table 2-1. The Haddon matrix of ski and snowboard injuries Host Agent Physical Environment Social Environment (Person at risk of injury) (Activity associated)

Pre-event • Knowledge • Safety equipment Participating when: • Peer pressure (injury (education about use • Weather conditions and how to prevention safety and adequate • Ski area rules & are good avoid before event) knowledge of rules guidelines • Terrain is engaging in and guidelines) • Type of activity appropriate and unsafe actions • Behaviour (teaching (ski or maintained due to peer students not to snowboard) • Appropriate slope influence engage in risky • Type of ski or conditions are • Listening to behaviour) snowboard present instructors • Learning and • Check rented Others: during lessons working on skills equipment • Awareness of signs • Skiing/ that help the • Make sure to • Removing snowboarding individual stay in adjust bindings distractions such as at appropriate control and buckle helmet music or use of distances from • Being on appropriate electronic devices others runs for ability level Event (injury • Knowledge about • Using protective • Terrain (incline, • Avoiding other prevention how to avoid equipment rolling hills, etc.) participants on during event) collisions, properly appropriately • Snow type/ the hill fall without injuring (helmet on conditions oneself, or proper properly using • Awareness of recovery during an 2V1 rule) physical event environmental factors that could result in further injury and avoiding fixtures on the ski

hill (example: noting location of chair lift towers and snow guns to avoid collisions) Post-event • Help-seeking • Ensure that • Access to medical • Rescue (How to deal behaviour equipment is attention procedure (ski with injury after • Not moving when functioning • Help from ski patrol patroller event) severely injured and properly after decides course waiting until help event of action when arrives dealing with injured individual) • Asking for help from peers

2.2.2 Skiing and Snowboarding Injury Burden and Risk Factors

Activities like alpine skiing and snowboarding require travel at relatively high speeds in variable environments. As skill levels improve, experts challenge themselves by attempting more dangerous manoeuvres such as acrobatic tricks and jumps 49,50. According to the Canada West

Ski Areas Association, during the 2008-2009 ski season, the injury rate for all participants was

1.64 per 1000 skier and snowboarder visits based on ski patroller reports 51. Orthopaedic (e.g., fractures, sprains) and head injuries are the most common types of injuries that are associated with skiing and snowboarding 52–57. There is evidence that knee injuries are the most common injuries in skiers while lower trunk (i.e., pelvis, hip, lumbar spine) and upper extremity injuries are the most common for snowboarders 52–57. Head injuries are the most common cause of death among skiers and snowboarders; young male snowboarders make up a high proportion of individuals who die from head injury 58–61. Skiers and snowboarders accept a certain amount of risk when participating in these winter activities and should be informed of risk factors for injury.

Risk factors associated with skiing and snowboarding can be extrinsic (e.g., weather, conditions) and intrinsic (e.g., age, sex) to the individual, as well as modifiable and non- modifiable. Modifiable risks factors refer to components that could be changed through injury prevention strategies. Non-modifiable risk factors are those that cannot be altered 62. Table 2-2 identifies potential intrinsic/extrinsic and modifiable/non-modifiable risk factors for skiing and snowboarding (adapted from Emery 2003 62). Those who are at greater risk of injury are first time participants, beginners, children and adolescents, males, those with improper binding adjustment, using rented equipment, having no formal training, and snowboarding 13,58,63–68.

Potential protective factors for those participating in skiing and snowboarding are proper protective equipment, adequate safety knowledge, and more experience 9,55,69. Other potential risk factors are specific to terrain parks where participants have a higher risk of injury relative to more traditional runs 70–72. Studies have identified half-pipe and jump features as significant risk factors for any injury and severe injury in both skiers and snowboarders 70–73. Many investigations have discussed the need for injury prevention programs to target ski hills that contain terrain parks and those who use them 70–72,74,75. In general, injury prevention programs that target modifiable risk factors such as safety knowledge, adequate equipment, and proper formal training are needed and might be beneficial within at-risk child and adolescent populations. More information is needed on modifiable behaviours such as risky behaviours.

Table 2-2. Potential Risk Factors for Injury in Skiing and Snowboarding Extrinsic Intrinsic Non-modifiable First Time Participants Age Slope Characteristics Younger Age Groups Weather (Children and Adolescents) Time of Day Sex Time of Season Previous Injury Potential Modifiable Type of Terrain (Icy or Activity (Ski or Snowboard) Groomed) Ability/Skill Level Use of Terrain Parks Lacking Safety Knowledge Binding Adjustment (Protective) Helmet Use (Protective) Proper Equipment (Protective) Peer-Pressure Properly Adjustment Equipment Formal Training (Protective) (Protective) More Experience (Protective) Rented Equipment Attempting Risky Behaviours

2.3 The Role of Behaviour in Skiing and Snowboarding Injury Prevention

Throughout the injury literature, there are numerous theories on behaviour and its role in injury prevention. Behaviour is defined as the way in which an individual conducts oneself or acts in response to a particular situation or stimulus 76,77. Many theories attempt to explain potential determinants of behaviour based on genetics, physiology, psychological factors, personality, environmental factors, and social factors 78. One theory on the role of behaviour within the injury prevention research states that injuries can be prevented by modification of risky behaviour 7. Another theory is that those who feel safer are more likely to engage in risky behaviour 79. Other theories focus on the development of behaviour and the effects of external factors, peer pressure and social determinants 78. We need to fully understand what role behaviour plays in reducing injuries on the ski hill.

2.3.1 Risky Behaviour in Sport Injury Prevention

Risk taking or risky behaviours can be defined as engaging in activities that have the potential to result in harm to oneself or others 80. It is believed that adolescents and young adults are the most likely age groups to engage in risky behaviours 81,82 as they may not understand the severity of the consequences 83. There is limited research on the role of risky behaviours causing injury in sport. Previous research suggests psychological traits (e.g., reward sensitivity, sensation seeking propensity), and psychological states (e.g., anxiety, depression) can influence a person’s engagement in risky behaviour 84. In addition, environmental factors such as peer-pressure and social norms have also been associated with risky behaviours, especially in younger age groups

85,86. In a different context, a study on risky behaviour among drivers suggested targeted

15 strategies to limit risky behaviours; for younger drivers, a peer-based approach was deemed best, while for older drivers a more individual approach was better 86.

Another issue that should be considered is the preventability of risky behaviours. Lunds and Aarø identified multiple factors that might influence injury prevention including behaviour, physical or organizational environment, attitudes and beliefs, and social norms and culture (see figure 2-1, adapted from Lunds and Aaro (2004) with permission) 87. Multiple studies have noted the important function attitudes and behaviours may play in injury prevention as most injuries can be predicted and prevented 87–89. A previous study that identified and assessed the perceived causes of winter sport injuries found the majority relate to poor decisions, actions, and human error 9. These findings were consistent with other studies that linked risky behaviour with injury

90,91.

Figure 2-1. An Accident and Injury Prevention model with emphasis on human, structural and cultural factors (Adapted From Lund, J., & Aarø, L. E. (2004) with permission. Accident prevention. Presentation of a model placing emphasis on human, structural and cultural factors. Safety Science, 42(4), 271-324.) 87

2.3.1.1 Assessment of Risk Taking and Risky Behaviours

Currently, there is no gold standard for assessing risky behaviour in skiing and snowboarding. It is important to consider what tools were used in the past to evaluate risky behaviour within skiing and snowboarding and their reliability. Multiple studies have examined risky behaviours through self-reports from skiers and snowboarders 92,93. Most studies that assess

17 risky behaviour are based on self-reported risky behaviours by participants or consider direct correlations between risky behaviour and injury incidence 90,94. This approach could underestimate the incidence of risky behaviours due to social desirability. Previously identified risky behaviours include lack of awareness of surroundings, insufficient skiing ability/experience, skiing errors, inadequate knowledge, excessive fatigue, excessive speed, not following rules, cutting off others, skiing too close to others, jumping unsafely, going on runs above ability level, stopping in the middle of the hill, near or actual collisions, and incorrect use of equipment 9,95–101. Part of this thesis will focus on the creation and evaluation of a risky behaviours assessment tool through skier and snowboarder observations at the hill.

2.3.2 Factors Associated with Behavioural Changes

Potential factors that may affect behaviour include safety equipment, previous injury, policies and legislation, and interventions 102–105. There is also a lack of information on factors affecting behaviour that can potentially lead to injury such as peer pressure and associations between risky behaviours and incidence of injury.

2.3.2.1 Safety Equipment

The proper use of safety equipment such as helmets, padding, and wrist guards is one of the most common recommendations to prevent skiing and snowboarding injuries 45,106,107. When investigating the risky behaviours of skiers and snowboarders, it is important to consider the role that safety equipment might play on injury risk and prevention. Risk compensation theory states that people tend to adjust their behaviour in response to their perceived level of risk; therefore, individuals may be more careful when there is greater risk and less careful when they feel more

18 protected 79. Most studies assessing the risk compensation theory in the context of skiing and snowboarding tend to focus on helmet use or other protective equipment. One study comments on helmet use as a significant predictor of engaging in risky behaviours in skiing and snowboarding 101; however, since helmets protect against head injuries, the benefits of using a helmet outweigh the cost of not using a helmet 60,61. Multiple systematic reviews on helmet use have found that wearing a helmet is associated with reduced risk of head injury among snowboarders and alpine skiers 61,69,108. Hagel & Meeuwisse examined the theory that the use of protective equipment in all sports can result in more injury based on risk compensation theory and reported that there was evidence showing that protective equipment reduces injury risk without increasing risky behaviours 109. The sport injury prevention literature suggests that protective equipment is effective and there is a lack of compelling evidence that shows risk compensation theory influences risky behaviours that result in injury.

2.3.2.2 Previous Injury and Experiences

The behavioural aspect of previous experiences with skiing and snowboarding and what happens after experiencing an injury are important considerations. Any negative previous experiences could lead to overly cautious approaches to activity or deterrence from all physical activity. An example of this would be if individuals may be less likely to return to that or similar activity due to fear of re-injury35–38. Positive behaviour changes could include more prophylactic measures to attempt to mitigate future injuries 7. Previous experiences may play an important role in behaviour change, and more information is needed about the mechanisms and effects of previous injuries on behaviour change.

2.3.2.3 Guidelines, Policies and Legislation

We should consider the effect of social norms, policies and guidelines, and the media on injury risk. Social norms are behaviours or ways of acting that are considered suitable in a group or society and there is limited information about how these social norms affect risky behaviours in a sport context 76,77. Lunds and Aarø discuss how cultures and norms in groups can change over time as a result of safety behaviours using examples from increased use of helmets when participating in bicycling 87. Within some skiing and snowboarding programs for children, it is mandatory for all students participating to wear helmets on the hill and for them to have proper instruction and equipment 110.

Legislation is another strategy that can lead to behavioural changes. The ski and snowboard literature suggests that helmet policies may prevent head injuries and multiple researchers have commented on the lack of legislation surrounding helmet use 55,58,61,108,111,112.

There are a limited number of locations with legislation mandating the use of helmets when participating with skiing and snowboarding 113–115. In addition, other recommended policies involve restricting ski area use to participants with certain ability levels to help decrease the chance of injury 112. Even though there is a lack of legislation around ski hill safety, there are still policies and guidelines in place to help distribute basic safety rules to prevent injuries. An example of this would be the Alpine Responsibility Code that is used in many countries to outline basic safety rules to prevent injury within the context of skiing and snowboarding 111.

Specifically, these guidelines include the following items111 :

1. Always stay in control. You must be able to stop, or avoid other people or objects.

2. People ahead of you have the right-of-way. It is your responsibility to avoid them.

3. Do not stop where you obstruct a trail, or are not visible from above.

4. Before starting downhill or merging onto a trail, look uphill and yield to others.

5. If you are involved in or witness a collision/accident you must remain at the scene

and identify yourself to the Ski Patrol.

6. Always use proper devices to help prevent runaway equipment.

7. Observe and obey all posted signs and warnings.

8. Keep off closed trails and obey area closures.

9. You must not use lifts or terrain if your ability is impaired through the use of

alcohol or drugs.

10. You must have sufficient physical dexterity, ability, and knowledge to safely load,

ride, and unload lifts. If in doubt, ask the lift attendant.

While these guidelines have been set in place, it is unknown if they prevent injuries or reduce risky behaviours. In addition, it is extremely difficult to change policies and legislation.

Equipment and environment are easier targets for injury prevention than attempting to change policy. However, there have been a few countries that have successfully implemented legislation mandating helmet use while participating in skiing and snowboarding for children 113–115. In addition, Nova Scotia (a province in Eastern Canada) is the first place in the world that has implemented a mandatory ski and snowboard helmet law that applies to both adults and children

113–115.

Other factors that might affect behaviours are media, mass communication through journalism or the web. There is inconsistent evidence on the effects of media on behaviour, and results from the literature have been inconsistent indicating that either media makes no difference or media can aid in changing behaviours and attitudes. In addition, mass media

21 campaigns have been shown to produce positive changes or prevent negative changes in health-related behaviours within large populations 116. Currently, most of the media is focused on the risks of injury and not the prevention mechanism. There are injury prevention ski and snowboard resources available such as the ‘‘Respect’’ and ‘‘A Little Respect: ThinkFirst’’; however, none of the studies assessing these resources have measured whether they change behaviours 111. Therefore, more research needs to be done on the effectiveness of ski and snowboard media to change behaviour and prevent injuries.

There are inconsistent results when examining changes in behaviour associated with educational interventions, previous experiences, social norms, media and current guidelines and safety policies. More information is needed on these factors and other potential determinants that might help change behaviours within the skiing and snowboarding injury prevention literature.

2.3.2.4 Interventions

There are several studies, within and outside the field of sport examining interventions for attitude and behaviour modification using education tools such as pamphlets, videos, brochures, leaflets, booklets, and posters; however, these studies have had mixed results in terms of associations between interventions and behaviour changes or the incidence of injuries 102–105.

(For more information on interventions see: 2.5 Interventions to reduce injury risk).

One concern is whether these interventions result in permanent or temporary behaviour changes, if any at all. The majority of these interventions focus on informing individuals about safety knowledge and the implications of not following rules, regulations and guidelines 117.

Therefore, it is important to consider the association between knowledge and risky behaviours.

2.4 The Role of Knowledge and Education in Skiing and Snowboarding Injury Prevention

Public health advocates believe that proper education can be a key strategy to help prevent injuries 10. Within the context of skiing and snowboarding, literature suggests that most children who were injured while participating in skiing and snowboarding either lacked safety knowledge or were not following the rules of the ski hill 99. This finding infers that prevention of injuries might be successful with education and proper knowledge translation; however, more evidence is needed to verify the association between safety knowledge and injury risk. In order to determine the role of knowledge on injury prevention in sport, it is essential to understand the knowledge acquisition process.

2.4.1 Associations between Behaviours and Knowledge

Understanding how individuals interpret risks and choose actions is vital to any strategy for injury prevention. One theory is that increased knowledge will modify attitudes on hazards and prevention and as a consequence, behaviour will change resulting in avoidance of injuries 117.

Literature has shown that understanding how to adjust and release ski bindings properly might be associated with the action of checking bindings more often, which can lead to a decreased injury risk 20. Yet, more evidence is needed to better understand the mechanism that resulted in these changes 20. Other studies and theories have also concluded that there is a limited, if any, effect of attitude and knowledge change interventions on behaviour and injuries 118. Covariates such as peer pressure, whom the behaviours were learned from, and environmental factors can also affect risky behaviours, even if knowledge dictates the actions should not be done (For information on risk factors for risky behaviours see 2.2.2 Skiing and snowboarding injury risk and risk factors

23 and 2.3.2 Factors Associated with Behavioural changes). There is limited information about the importance of knowledge for influencing behaviour change.

2.4.2 Knowledge acquisition and uptake

There is some evidence to suggest that injury risk might be reduced knowledge uptake.

Knowledge is defined as the awareness of facts and information or familiarity of skills; acquired by a person through experience or education; or the theoretical or practical understanding of a subject 76,77. Knowledge can be acquired in a number of different ways: observation, social norms, cultural practices, societal beliefs, use of logic, intuition, modeling, copying actions and more 119. Environmental factors such as surroundings, media, parental influences, education, and age can influence what knowledge is acquired.

Knowledge can be acquired and changed in many different ways. For example, multiple studies have been conducted on knowledge change and concussion symptom recognition and management after concussion education interventions 120–124. Many of these studies reported a positive effect of concussion education interventions on symptom recognition, injury management and misperceptions of how to treat head injury 120–124. Gender and age are two covariates that may influence knowledge acquisition. There are no current studies examining differences in injury prevention knowledge acquisition within sport settings in different age groups. One study on concussion recognition and management found that both males and females improved their test scores significantly after a workshop 120. Multiple studies have shown that increased knowledge on safety practices and proper equipment use results from the implementation of educational interventions within sports such as rugby, squash, skiing and snowboarding 19,125–129.

One other consideration is how knowledge can translate into sport performance when youth are learning skills, applying strategies and performing appropriate actions 130. There is little information about knowledge translation into practice at the ski areas; therefore, it was necessary to explore knowledge acquisition outcomes in other sports (For more information on search strategy see Appendix A: Search Terms for Literature Review). Studies in basketball and tennis provide evidence for the importance of developing sport knowledge and how sport knowledge plays a significant role in skilled sport performance of children. However, these studies did not address injury in sport 131,132. This also leads to the question of whether skill level has an affect on knowledge acquisition. Literature indicates that in most cases players with greater skill have a larger and more elaborate knowledge base 131,133. Multiple studies state that knowledge plays a key role in strategy and proper skill performance within sport 133–136. A skiing and snowboarding study found that those children who were injured were more likely to lack safety knowledge or were not following rules 99. However, research needs to examine the associations between knowledge, risky behaviours and injury risk, considering people may adopt actions even in times when they are known to be unsafe or unconventional.

2.5 Educational Interventions to Reduce Injury Risk

Multiple theories on injury prevention consider the association between injury and knowledge. Education about the risks of injury, injury prevention strategies, and proper management are frequently stated as crucial measures for injury prevention 10. Methods of knowledge translation include pamphlets, brochures, leaflets, booklets, posters, websites, training programs, and videos 19,20,99,104,137,138. These sorts of interventions provide a potentially cost-effective, relatively easily implemented method for injury prevention; however, it remains

25 unclear which type of educational intervention may be most effective and efficient for preventing sports-related injuries. Lastly, it is important to consider how our intervention was developed and why it can be implemented in place of other interventions.

2.5.1 Lesson and Training Programs

Training programs might be an effective way for translating knowledge into action.

These programs can take multiple forms, including teaching skills, warm-up programs, or focusing on technique to prevent specific injuries. There are no studies within the skiing and snowboarding literature that describe the effectiveness of safety training or lesson programs.

However, a study in swimming found that a 12-week intervention that included swimming, survival and rescue skills, along with water safety knowledge applicable to a range of aquatic environments was successful in improving knowledge and swim ability in participants 137. Proper acquisition and practice of these skills can potentially result in more preparedness while participating in activities. Currently, skiing and snowboarding lessons are intended to teach participants proper techniques, skills, and procedures 110.

2.5.2 School-based Educational Interventions

School-based interventions are a way to disseminate knowledge to large groups and help inform individuals about the importance of safety and the potential dangers that might be associated with actions. This is important for students who are participating in activities as a part of a school curriculum. Evidence shows that education-based interventions aimed at reducing injuries in sport can increase knowledge of safety behaviours, and injury mechanisms, symptoms, and management. Multiple education-based injury prevention programs have led to

26 positive behaviour changes in school or team based settings121–126,128,129. However, none of these educational interventions decreased injury rates. A review on educational-based interventions that aimed to reduce unintentional injuries to children in the outdoors reported mixed results 139.

Multiple intervention studies have been done in through schools within swimming, biking, and skiing-snowboarding and show promising results for increased knowledge measured by comparisons between pre- and post-test scores. An education intervention program delivered to school-aged children found that intervention mechanisms such as pamphlets and videos were successful and effectively increased ski and snowboard safety knowledge by 20%. In other school-based programs in sports such as swimming, the findings of a water safety intervention that consisted of an audio-visual presentation, discussion, play, and take home materials indicated that individuals receiving the intervention scored significantly higher for knowledge and attitudes on post-tests compared with pre-tests140. The intervention was also found to be more effective in younger age groups 140. These results suggest that educational interventions might be more effective if targeted to younger, perhaps more receptive populations.

Even though these studies on school-based interventions have shown positive effects on knowledge, most studies used multiple delivery modes and so it is unclear which components are most effective. Many of these studies were limited by small sample sizes so larger investigations are needed.

2.5.3 Video Interventions

Numerous injury prevention studies have used video interventions in an attempt to increase safety knowledge and introduce prevention strategies that can lead to adoption of certain

27 desirable behaviours. Previous studies have been able to show the effectiveness of video interventions on increasing knowledge in snow sports such as skiing and snowboarding 20,138,142.

One of the first evaluations showed that a 45 minute video intervention resulted in decreased risky behaviour, increased binding checks and adjustments, and fewer of injuries 20.

However, this randomized controlled trial was conducted in both adults and children20. Another study assessed the effectiveness of using brochures and a video intervention among junior high students in skiing and snowboarding programs and found the intervention increased safety knowledge and changed attitudes and behaviours towards skiing and snowboarding injuries; however, the authors could not link these behaviours to a significant reduction in injures19.

Using this information from previous literature, the aim of this project was to develop and conduct a pilot evaluation of injury prevention programs for youth skiing and snowboarding programs. Previous studies have shown the effectiveness of a video intervention on increasing knowledge in children and adolescents in other sport and recreational activities. An intervention study found that a bicycling video with a structured discussion about safety rules was successful in increasing knowledge among children and the information appeared to be retained over a 2- month period of time 143. However, a systematic review of interventional studies on bicycle safety indicate no effect of these programs on injuries 144. Within an ice hockey study, it was found that a single viewing of an educational video could immediately improve knowledge about concussion in adolescent populations 8; though, the improved knowledge was lost after 2 months and there were differences in retention between different age groups and the older age group did better 8.

Most video intervention studies tend to look at pre-test and post-test scores, directly before and after watching video interventions without considering the knowledge retention after

28 longer follow-up times. There are no relevant sport injury prevention ski and snowboard studies that report on follow ups done within a month of exposure to any intervention. Therefore, future studies should investigate effects of interventions one month and longer after implementation.

Many studies have investigated the effect of video interventions in reducing the risk of injury by increasing knowledge on injury risk and prevention mechanisms that may lead to behavioural changes; yet, most intervention videos do not consider any behaviour theory or framework to promote the targeted behavioural change. More research is needed about intervention development and the effectiveness of utilizing a theory or framework such as the

Health Action Process Approach (HAPA) behavioural maintenance model to promote behavioural change145.

2.5.4 Development of Video Intervention for this Thesis Project

There has been no consistent or comprehensive injury prevention program developed or implemented in the context of school sanctioned ski and snowboard programs at a Southern

Alberta ski area. Members of the ski industry have expressed the need for such a resource

(Appendix B: WinSport reference letter). This project focused on the implementation and evaluation of a video intervention aimed at educating children and youth about the risk of injuries and effective strategies to prevent them, while still promoting participation in snow sports. The video was developed with input from injury prevention experts and industry professionals and incorporated content and format suggestions based on three rounds of ski patrol/instructor, parent and child skier and snowboarder focus group feedback. In addition, a

29 professional multimedia company was used for the editing and filming phases. (For more information see Appendix C: Video Intervention Development).

CHAPTER THREE: VIDEO INTERVENTION AND KNOWLEDGE

3.1 Introduction

Skiing and snowboarding are common winter activities resulting in approximately 2.5 million and 78 million ski area visits annually in Alberta and North America, respectively 1,2. At least 20% of these visits are by children and adolescents 1,2. With participation in these snow sports, there is potential for injury due to a number of factors including variable weather conditions, high speeds, acrobatic manoeuvres and lack of space regulations that enforce appropriate distances between participants on the ski hill 49,50,146. Based on ski patrol injury reports from the Canada West Ski Areas Association during the 2008-2009 ski season, the reported injury rate was 1.64 per 1000 skier and snowboarder visits 51. Research has consistently reported that the injury rate is higher for snowboarders compared with skiers and younger or first-time participants 13,67,147–149. MacNab et al. reported that the highest injury rate in skiers and snowboarders was among children and adolescents aged 7 to 17 years old and the authors speculated nine out of ten injuries were potentially preventable if children were adequately educated about safety 99.

Many public health advocates categorize injury prevention strategies in terms of the 3

E’s: enforcement, engineering and education 10. Enforcement refers to reinforcing safety regulations and sports policies; engineering refers to safety equipment design and safer environments used to play and practice; and education refers to increasing awareness of high risk manoeuvres that could lead to injuries, best practices and encouraging the adoption of safer behaviours 10. Many studies have also shown an association between increased knowledge and

31 lowered injury risk in the sport and recreation setting 9,62,150–157. Within the academic community, it is a common belief that injuries are predictable and that many can be prevented through education 9. Current literature on skiing and snowboarding educational interventions has focused on the use of a mix of brochures, teaching sessions, and videos to educate skiers and snowboarders about safety 19,20. Yet, there is still limited information on the effect of educational interventions in skiing and snowboarding school programs, indicating the need for additional research 1,2,51.

In the past, incorporation of safety videos has been a successful way to increase safety knowledge and potentially induce behavioural changes in a number of sports 8,19,20,141,143,158.

Jørgensen et al. reported that a 45-min instructional safety video focused mainly on equipment improved safety behaviour and knowledge of proper adjustment of ski bindings for adult participants during an eight-day ski trip 20. A study of a 20-minute intervention video on ski and snowboard safety and additional brochure found that junior high students exposed to this intervention improved their general knowledge 19. However, no video intervention exists examining younger skiers and snowboarders to determine if they can increase their knowledge.

Therefore, the primary objective of this study was to conduct a cluster randomized controlled trial to determine whether an educational video intervention, including injury prevention messages, would increase ski and snowboard school program participants’ (grades 2-9; ages 7-

16) safety knowledge compared with a general ski hill orientation video. A secondary objective of this study was to investigate knowledge maintenance one month after students watched their assigned video.

3.2 Methods

3.2.1 Study Design

This study was part of a cluster-randomized controlled trial examining the effect of a ski- snowboard safety video on knowledge, risky behaviours and injuries.

3.2.2 Participants

Elementary and junior high schools participating in skiing and snowboarding school programs at a Southern Alberta ski area were recruited for the study. A total of 100 schools

(n=12,080 students) in the area were registered in the ski and snowboard school programs at the time of recruitment for the 2016-2017 season (See Appendix M: Participant recruitment details).

Once schools agreed, consent and assent forms were sent to all students. To be a part of the study, parental consent and child assent was required (See Appendix G: Consent form and

Appendix H: Assent form).

3.2.3 Randomization

The randomization process was done a-priori and we planned to have schools stratified

(Jr. High vs. Elementary) by block randomization with block sizes of 2, 4 and 6. After randomization, students watched the intervention or control video prior to participating in the ski and snowboard lessons programs. The research coordinator was aware of the intervention status of all schools and administered the videos and tests while the MSc student (TM), responsible for data analysis and interpretation, and other research assistants (RAs) associated with the project were blinded to group status until all elements of data analysis and interpretation were completed and the manuscript was written.

3.2.4 Control Group

The control group watched a standard eight-minute school program overview video with information on how their day would go and how to use and put on safety equipment

(https://www.youtube.com/watch?v=ReO148qwv7c). This link was never supplied to students randomized to the control group.

3.2.5 Intervention Group

The intervention group watched a ten-minute ski and snowboard injury prevention video including information on correct protective equipment use and strategies for speed control and collision avoidance. The video development was based on feedback from experts and focus groups guided by the Health Action Process Approach model, which is a built in framework to encourage behavioural change and maintenance 159 (See appendix C for Video development and

Appendix D for ski and snowboard safety video script).

3.2.6 Procedures

(For detailed procedures see Appendix N: Detailed Procedure Knowledge and Behaviour)

Students were exposed to the intervention or control video between 4 days to 3 weeks before participating in a school outing to the ski area. Prior to showing the assigned video and starting the data collection process for knowledge outcomes, parental consent and child assent was obtained (see Appendix G and H for Consent and Assent Forms). The research coordinator presented the same introduction to all students explaining the pre-test, video and post-test.

Students completed the pre-test capturing information on demographic data and 15 questions

34 about skiing and snowboarding safety, watched the assigned video, and then immediately completed the post-test of the same 15 questions after the assigned video (see Appendix O: Pre- test and post-test). The protocol ensured consistency in how the videos were delivered across all schools. Students were told that they were going to fill out some demographic data and answer

15 questions on skiing and snowboarding then watch a video and after answer the same 15 questions. The research coordinator indicated that the tests would not be graded, but that they should try their best. Students had completed paper copies of the pre- and post-tests that were collected by the research coordinator and ID numbers (school id- class id- individual) were placed on every page.

Data were entered into a REDCap database160 and then the forms were locked in a secure office space at the Alberta Children’s Hospital. A 10 percent verification process was completed from 1034 knowledge assessments collected, where a research assistant and a research coordinator used STATA software161 to randomly select 105 ID numbers and then verified the accuracy of the data entry forms. One month after viewing their assigned video, students were sent a an email with a link to an electronic questionnaire consisting of the same 15 questions.

The link to the follow up test was not deactivated after a specific date. Students were instructed to complete the follow up test on their own without help from their parents.

3.2.7 Outcome measurements

The primary outcome was change in pre- to immediate post-test score. The test consisted of 15 questions that were designed to assess ski and snowboard safety knowledge. The test consisted of 10 multiple choice questions with three or four possible responses depending on the question along with five “true or false” questions. In terms of content, the test contained 5

35 general safety knowledge questions, 3 helmet questions, 1 preparedness question, 2 collision avoidance questions, 3 questions about hill difficulty signage and 1 question on what to do if you encounter someone with an injury on the slope. Both the control and intervention groups completed a post-test consisting of the same questions after watching their assigned video.

The secondary outcome for this project was change in test score one month after viewing the video to gauge maintenance of safety knowledge measured by administering the same 15 questions and comparing the 1-month post-test scores to the immediate post-test scores.

3.2.8 Analysis

3.2.8.1 Sample size

The sample size was calculated based on the assumption of a two-sided alpha significance level of 0.05, a power of 80%, difference between groups (of change variable) of 5 points, and standard deviation of 2.97 (based on a study done on general injury prevention knowledge at junior high schools in Calgary (See Appendix S: Sample Size Calculations for more information). Hayes and Bennett suggest the coefficient of variation for most health outcomes would not exceed 0.5 162. Under the abovementioned assumptions, we would need approximately 3 schools per group, so approximately 90 students per arm and 180 students total. Under the same assumptions, except with a larger coefficient of variation of 1.5, we would need 19 schools in each arm of the study (38 schools total and 1140 students). (See Appendix S:

Sample Size Calculations for more information).

3.2.8.2 Analysis Plan

Knowledge uptake was assessed by examining the difference in the test scores

(proportion responses out of the total number of test questions) before and after either the

36 intervention or control video was shown to each student, and whether mean change scores with 95% confidence intervals (CIs) between the pre- and immediate post-test differed in the intervention and control group. Linear regression was used to assess the effectiveness of the video intervention in improving knowledge based on change scores while controlling for important covariates (including: grade, gender, previous experience, and self-reported ability

13,51,92,163). Classroom level clustering was also taken into account for the analysis 164. Interaction terms between all covariates and intervention status were tested using a likelihood ratio test and any interaction term that was not statistically significant was removed from the model. These analyses were repeated for the 1-month post-test to assess longer-term knowledge retention by comparing the 1-month post-test to the immediate post-test scores for each group.

3.3 Results

Figure 3-1. Flowchart of schools and participants involved within the study

Out of the hundred schools participating within the school programs, eighty schools were approached for recruitment, but declined participation due to school administration not agreeing to participate, inability to schedule the initial school visit before the outing, or having students outside the age criteria (Figure 3.1). Twenty schools with 2728 students responded to the invitations and agreed to be part of the study. However, two schools were considered lost to follow-up since a data collection session could not be scheduled in a timely manner prior to the school’s first outing to the local ski area. In addition, one school did not send out any consent or assent forms; therefore, the school did not participate. In total, 17 schools in the Southern Alberta area (n=2302 students) were randomized to either the intervention or control video at the school level. Of the 2302 students from the 17 schools, parental consent and child assent was obtained for 1034 students (44.92%). Overall, 646 students were in the control Group and 388 were in the intervention Group) (Table 3-1). A total of 251 students completed the 1-month post-test (129 control group and 122 intervention group students) within a two-week period after the one month follow up was sent out.

Table 3-1. Characteristics of participating students in the control and intervention groups Control Group Intervention group Numbers (percent of Numbers (percent of total control group) total intervention group) Number of Schools: 10 7 Number of Students: 646 388 Grade Range: 2-8 2-9 Grade: 2 38 (5.88) 44 (11.34) 3 47 (7.28) 57 (14.69) 4 179 (27.71) 69 (17.78) 5 119 (18.42) 136 (35.05) 6 67 (10.37) 11 (2.84) 7 94 (14.55) 21 (5.41) 8 102 (15.79) 27 (6.96) 9 0 (0.00) 23 (5.93) Gender: Male 332 (51.39) 168 (43.30) Female 302 (46.75) 217 (55.93) Other 1 (0.15) 2 (0.52) Missing 11 (1.70) 1 (0.26) Ski Experience: Yes 419 (66.86) 267 (68.81) Mean Years if yes 3.51 years (SD: 2.07) 3.76 years (SD: 2.56) No 212 (32.82) 102 (26.29) Snowboard Experience: Yes 181 (28.02) 91 (23.45) Mean Years 2.56 years (SD: 1.71) 2.43 years (SD: 1.85) No 444 (68.73) 277 (71.39) Self-Reported Ability: Beginner 216 (33.44) 102 (26.29) Intermediate 240 (37.15) 136 (35.05) Advanced 113 (17.49) 84 (21.65) Do not Know 57 (8.82) 38 (9.79)

Table 3-2 indicates that the mean baseline pre-test scores were similar between control group (11.62; 95% CI: 11.48-11.76) and intervention group (11.82; 95% CI: 11.63-12.01). After viewing the assigned video, the control group’s mean score was 11.72 (95% CI: 11.57-11.88)

40 while the intervention group’s mean score was 13.73 (95% CI: 13.58-13.88). The mean change score between the pre-test and immediate post-test for the intervention group was 1.91

(95% CI: 1.73-2.08), while the mean change score for the control group was 0.10 (95% CI: 0.00-

0.22). The mean 1-month post-test score for the control group was 12.71 (95% CI: 12.49 -12.92) and for the intervention group was 13.90 (95% CI: 13.61- 14.19). The mean change score was

0.60 (95% CI: 0.28 -0.93) and 0.00 (95% CI: 0.32 -0.32) for the control and intervention groups, respectively (Table 3-2).

Table 3-2. Mean scores pre-, post- and 1-month post- tests for control and intervention groups Mean Score Pre-test (95% CI) Immediate Post-test 1-month Post-test (95% CI) (95%CI)

Control 11.62 (11.48-11.76) 11.72 (11.57-11.88) 12.71 (12.49-12.92) Group

Intervention 11.82 (11.63-12.01) 13.73 (13.58-13.88) 13.90 (13.61-14.19) Group

From table 3-3, after the assigned video, 91.75% of the students in the intervention group answered question 11 (helmet fit) correctly on the immediate post-test and 41.24% of the students also answered question 13 (helmet fit) correctly after the intervention video. A greater proportion of students in the intervention group answered questions 2 (safety knowledge), 14

(Alpine Responsibility Code), and 15 (safety knowledge) incorrectly on the immediate post-test after exposure to the intervention video. In the control group, a greater proportion of students incorrectly answered questions 4 (safety knowledge), 6 (safety knowledge), 7 (safety

41 knowledge), 14 (safety knowledge), and 15 (safety knowledge) more often after the control video (Table 3-3).

Out of the 1034 participants, only 251 completed the 1-month post-test knowledge questionnaire; 129 (19.9%) from the control group and 122 (32.5%) from the intervention group

(Table 3-4). When comparing the 1-month post-test to the immediate post-test, more students in the intervention group answered question 2 (safety knowledge), and 15 (safety knowledge). A greater proportion of students in the control group answered questions 6 (safety knowledge) and

7 (safety knowledge) correctly. A greater proportion of students in the intervention group answered questions 8 (identifying signs), 11 (helmet fit), and 13 (helmet fit) correctly on the immediate post-test after answering these questions incorrectly on the pre-test, while a higher proportion of those students in the control group answered all questions correctly compared with the immediate post-test (Table 3-3).

Table 3-3. Proportion of students who answered each question correctly by test and intervention group Question Pre-test Pre-test Immediate Immediate 1-month Post-test 1-month Post-test Control Group Intervention Post-test Post-test (n=129) (n=122) Group Control Intervention Control Group Intervention Group Group Group 1 (general readiness) 97.99 98.20 98.14 98.71 99.60 100.00 2 (collision avoidance) 85.76 89.69 87.46 78.61 96.12 99.17 3 (collision avoidance) 90.87 89.18 91.18 93.3 94.53 96.64 4 (safety knowledge) 85.76 88.66 84.98 93.56 94.53 95.04 5 (safety knowledge) 80.80 82.22 81.73 87.11 84.50 91.67 6 (collision avoidance) 45.98 51.80 45.82 65.46 65.12 70.25 7 (injury avoidance?) 76.93 84.79 73.84 87.63 86.82 90.08 8 (identifying signs) 89.32 88.40 91.18 96.65 95.35 92.56 9 (identifying signs) 87.77 88.92 91.02 96.91 95.35 95.04 10 (identifying signs) 89.94 91.49 92.57 97.16 98.45 97.52 11 (helmet fit) 6.81 4.64 7.59 96.39 10.94 84.03 12 (helmet fit) 78.17 75.00 80.19 96.91 84.50 98.35 13 (helmet fit) 51.24 55.67 57.43 96.91 66.67 95.04 14 (safety knowledge) 95.98 95.88 94.12 94.07 99.22 100.00 15 (safety knowledge) 98.45 97.68 95.36 93.56 98.44 100.00

Table 3-4. Characteristics of control and intervention group students completing the one-month post-test Control Group Intervention group Numbers (percent Numbers (percent compared to total compared to total control group) intervention group) Number of Schools: 10 7 Number of Students: 129 122 Grade Range: 2-8 2-9 Grade: 2 7 (5.43) 8 (6.61) 3 13 (10.08) 16 (13.32) 4 49 (37.98) 28(23.14) 5 23 (17.83) 46 (38.02) 6 13 (10.08) 5 (4.13) 7 12 (9.30) 5 (4.13) 8 12 (9.30) 8 (6.61) 9 0 (0.00) 5 (4.13) Gender: Male 76 (58.91) 47 (38.52) Female 53 (41.89) 73 (59.84) Other 0 (0.00) 2 (1.64) Ski Experience: Yes 84 (65.62) 99 (75.63) Snowboard Experience: Yes 39 (30.23) 27 (22.50) Self-Reported Ability: Beginner 46 (35.94) 35(29.17) Intermediate 44 (34.38) 45(37.50) Advanced 29 (22.66) 32 (26.67) Do not Know 9 (7.03) 8 (6.67)

From Table 3-5, 328 students (84.53%) in the intervention group had at least a 1- point increase on the post-test compared with the pre-test, and 221 students in the intervention group (58.9%) had a 2-point or greater increase. 200 students (30.96%) in the control group had at least a 1-point increase on the post-test compared with the pre- test and 77 students (11.90%) had a 2-point or greater increase (Table 3-5). 37 students

(30.33%) in the intervention group had at least a 1-point increase on the 1-month post- test compared with the immediate post-test, while 58 students in the control group

(45.00%) had at least a 1-point increase on the 1-month post-test compared with the immediate post-test (Table 3-5).

Table 3-5. Proportion of students who did better (1 point or more increase in score), worse (1 point or less decrease in score) or the same (no change in score) comparing pre-, post- and follow-up tests Group Immediate Number Immediate Number Post-Pre (Percentage) Post- 1 month (Percentage) change score post-test change score Control Better 200 (30.96%) Better 10 (7.75%) Same 13 (10.08%) Pre- and post- Worse 15 (11.62%) n=646 Same 302 (46.75%) Better 29 (22.48%) Same 26 (20.16%) 1-month post- Worse 11 (8.53%) test versus post- Worse 144 (22.29%) Better 19 (14.72%) n=129 Same 5(3.88%) Worse 1 (0.78%) Intervention Better 328 (84.53%) Better 27 (22.13%) Same 45 (36.89%) Pre- and post- Worse 35 (28.69%) n=388 Same 45 (11.60%) Better 9 (7.38%) Same 3 (2.45%) 1-month post- Worse 1 (0.82%) test versus post- Worse 15 (3.87%) Better 1 (0.82%) n= 122 Same 0 (0.00%) Worse 1 (0.82%)

Linear regression demonstrates a significant difference (p<0.0001) between the intervention and control group in terms of pre- and immediate post-test change score

(Table 3-6). The beta coefficient for the estimate of mean change score was 1.79 (95%

CI: 1.52-2.06) for the intervention group based on the linear regression. The covariates considered included grade, gender, previous experience skiing or snowboarding and self- reported ability and interactions between any of these five variables and intervention status. All models accounted for clustering by class. A likelihood ratio test between a

45 model with and without interaction terms indicated that the interaction terms were not significant and could be removed from the model (likelihood ratio test p= 0.136 in presence of clustering by class). Grade was a continuous variable centered at grade 2, and between an increment of one grade (example: grade 3 to grade 4 or grade 7 to grade 8), there was a -0.06 (95% CI: -0.13-0.01) mean change score. In addition, no covariates confounded the association between video and change in knowledge (indicated by comparing estimates with and without the covariates in the model and determining that no covariate changed the intervention effect estimate by 10% or more).

Table 3-6. Linear Regression of pre-test compared with immediate post-test change scores based on the effect of intervention status adjusted for other covariates and clustering by class. Variable Beta Coefficients for the 95% CI estimates of mean change score Intervention or control 1.79 1.52-2.06 group (Reference control group) Gender -0.01 -0.23-0.22 (Reference females) Grade -0.06 -0.13-0.01 Snowboard Experience 0.13 -0.11-0.36

Ski Experience 0.09 -0.15-0.33 Ability (Reference beginner) Intermediate -0.34 -0.64--0.04 Advanced -0.22 -0.54-0.11 Do not know 0.06 -0.34-0.47 Constant 0.09 -0.65-0.83

The linear regression analysis indicated a significant difference (p=0.0008) between the intervention and control group in terms of immediate post- and 1-month post-test change score in those completing both tests (Table 3-7). The beta coefficient for

46 the estimate of mean change score was -0.67 (95% CI: -1.16- -0.18) for the intervention based on the linear regression. As in the pre- to immediate post-test linear regression, we found similar results that none of the covariates including grade, gender, previous experience skiing or snowboarding and self-reported ability modified the relationship between change scores and intervention status (Table 3-7). There was no evidence of confounding across all covariates as assessed by comparing estimates with and without the covariates in the model.

Table 3-7. Linear Regression of immediate post-test compared with 1-month post- test change scores based on the effect of intervention status adjusted by other covariates clustered by class

Variable Beta Coefficients for the 95% CI estimates of mean change score Intervention or control group -0.67 -1.16- -0.18 (Reference control group) Gender -0.30 -0.78-0.18 (Reference females) Grade -0.02 -0.19-0.15 Snowboard Experience 0.08 -0.44-0.60 Ski Experience 0.14 -0.44-0.73 Ability (Reference beginner) Intermediate 0.11 -0.52-0.73 Advanced 0.62 -0.05-1.30 Do not know 0.52 -0.63-1.67 Constant 0.54 -1.35-2.43

3.4 Discussion

This project has demonstrated that the use of an intervention video with injury prevention messaging increased ski and snowboard safety knowledge among grade 2-9 students participating in school programs. Overall, the intervention group had a 1.91- point increase in test scores after watching the intervention video, while the control group had a small, non-statistically significant difference in change scores. This could be clinically significant as a one-point increase in knowledge on the immediate post-test could be practically applied at the ski area and result in individuals knowing more about safety knowledge and practices, proper helmet fit, correct sign identification and/or techniques to avoid collisions. In addition, this project is the first within the skiing and snowboarding literature to consider knowledge retention 1 month after an education video intervention. Although relatively few students completed all three tests, our results indicate that those who watched the intervention video were able to retain their knowledge after the 1-month follow up mark.

The intervention video was successful in increasing safety knowledge overall.

However, there are still anomalies such as 11% of students in the intervention group who did worse on questions that relate to what skiers and snowboarders should be aware of when going down a run. A possible explanation may be that students did not understand the video messaging. Both the control and intervention group had several students who did worse on questions associated with the Alpine Responsibility Code after exposure to their videos, which suggests that watching the intervention video may not adequately address the material covered by these questions. The video content may need to be modified to address this gap.

During the 1-month post-test, some students in the intervention group did worse on questions on identifying signs and helmet fit, compared with the immediate post-test.

Students in the control group demonstrated an increase in their knowledge after the 1- month period, indicated by 44.95% of students who completed the 1-month post-test and scored better on the follow up compared with the immediate post-test. This could be the result of learning the material through the ski lessons at the hill and the practical experience at the ski area.

In the intervention group, over 70% of students did the same or better on the 1- month post-test compared with the immediate post-test. This may be explained by reinforcement of key concepts at the ski hill during their lessons. This study indicates that, among those who completed the 1-month post-test, knowledge transfer from the video was retained by students in the intervention group; however, we cannot state this was a direct association with the video intervention as other factors such as school program lesson content may have also affected student knowledge. Future research that involves a 1-month follow-up test should include a question asking what other learning modalities students have been exposed to since watching the intervention or control videos. This could include additional education materials in the classroom or separate lessons on the weekends. Although, we would not necessarily expect this to be different for intervention versus control groups.

Our findings are similar to the results found in previous research such as

Jørgensen et al., and Cusimano et al.,, which suggest videos can effectively increase knowledge; however, this study indicates the intervention video alone can function to increase knowledge within a child and adolescent school population that can be measured

49 through the use of pre- and immediate post-tests 8,19,20. This is a critical first step as children and adolescents are at risk for preventable incidents and learning proper practices early on may lead to better adherence throughout life 9,67,99. It is important to note that educational videos, such as “Respect” and “A Little Respect: ThinkFirst!”, have been recommended in the past to help students in ski and snowboard programs to better understand ski and snowboard safety 111,142; however, the recommendations to view the video have been removed from the official websites due to the out-dated nature of the video. Therefore, a new video that contains updated knowledge and practices would be useful. Showing students what their day will look like and exposing them to proper injury prevention strategies, hill rules, and guidelines on the hill might help reduce incidents

(that could lead to injury) due to inadequate safety knowledge.

Our study has some limitations, which included some school boards, and schools not consenting to be part of our study. It is possible that the schools that consented were systematically different from those that did not consent, such as different socioeconomic backgrounds. If this were true, the students attending schools from lower socioeconomic neighbourhoods may have gained more from the video (e.g., not having other opportunities to ski and snowboard), but were not included from the study. If this were true, the intervention video may be more effective at increasing knowledge even more than what we found. Second, even though the schools were randomized, participation from individuals had to be voluntary, and so only a portion of students from each school consented and provided answers to all three tests. We had high attrition rates for the 1- month post-test, however, when comparing tables 3-1 and 3-4, there are similar proportions of each grade, gender, ability and experience. Most students in both groups

50 had skiing and/or snowboarding experience, which might have been due to previous participation within the ski and snowboard programs or participating with friends or family (66% of participants self-reported skill levels of higher than beginner); therefore, participants in both groups might not have gained as much information as others who were unfamiliar with the activity. Third, we did not collect information on what activity students were going to participate in (skiing vs. snowboarding), so it cannot be determined if the intervention video was effective in both ski and snowboard groups at improving knowledge. This could be problematic as there are extensive differences between skiing and snowboarding in equipment and culture 67. Fourth, children and adolescents may not have been attentive and actively paying attention to all the information that was presented for their assigned video. This would result in similar scores on the immediate post-test within both groups. In addition, students were told the test was not graded and would not count towards their report card, but were asked to simply try their best. If students did not take the test seriously, they may have selected the wrong answers on either the pre-test or immediate post-test. Again, this would underestimate the effectiveness of the intervention video as it would represent non- differential misclassification affecting both groups.

Finally, we should consider that knowledge transfer and acquisition of safety knowledge might not result in direct adoption of safe behaviours and actions. The Health

Action Process Approach (HAPA) is a behavioural maintenance model that was used as the theoretical foundation of the video intervention in order to create a tool with measurable, evidence-informed pathways to behaviour change and maintenance in children 145. However, even with this built into the framework of the video intervention,

51 research has not proven that knowledge change alone is sufficient to produce changes in behaviours and multiple other factors can result in behaviour deviations even with proper safety knowledge. More work is needed to further evaluate the association of safety knowledge, behaviour and ultimately injuries in youth skiers and snowboarders.

3.5 Conclusion

This study demonstrates an increase in safety knowledge in elementary and junior high students following a ski and snowboard video intervention compared with a control video. In addition, one month after a single viewing, some participants were able to retain knowledge based on the information presented in the video.

CHAPTER FOUR: BEHAVIOURAL TOOL DEVELOPMENT AND

ASSESSMENT

4.1 Introduction

Skiing and snowboarding are activities that involve high speeds and aerial manoeuvres on slippery and unpredictable terrain 165,166. Therefore, participants accept a certain level of injury risk when participating in these activities and the associated injuries range in severity from minor scrapes or overuse injuries to fatal and catastrophic trauma 165. Ski and snowboard helmets, other protective equipment, and better methods of disseminating safety knowledge have been the focus of recommendations to reduce injury risk; however, few studies have considered risky behaviour that can lead to injuries

7,92,138,142. Risky behaviours have been identified as a leading determinant of injury in both adults and children89,167–170. Risky behaviours are an extremely common part of sport, especially in activities such as skiing and snowboarding. Chamarro and Fernandez-Castro identified and assessed the perceived causes of injury events in snow sports and noted that the majority of injuries are due to poor decisions, risk taking actions, and human error 9.

Analyzing the role of risky behaviours is essential for gaining a comprehensive understanding of sport injury prevention, yet it still remains an under-researched area 7.

To better understand the role of risky behaviour within these sports, better ways to identify and assess risky behaviours are needed. Currently, there are no tools to assess and evaluate risky behaviours in the context of skiing and snowboarding. Most of the studies assessing risky behaviours focus on participant self-report or judge equipment

53 practices 92,93,101,171–173. In addition, causes of injuries are normally linked to risky behaviours 9; therefore , if a risky behaviours tool picks up part of the path that could lead to injury, then injury prevention strategies can be evaluated without solely focusing on injury outcomes.

The main objective of this study was to develop and assess the accuracy and reliability of a Risky Behaviour and Actions Assessment Tool that allows consistent assessment of risky behaviours on the ski hill among beginner skiers and snowboarders.

4.2 Methods

4.2.1 Development of the Tool

A list of known risky behaviours was created based on the scientific evidence, personal communication with ski and snowboard experts, focus group research and the

Alpine Responsibility Code. Identified risky behaviours included obstructing the hill in any way, cutting off other participants, skiing too close to others, not following hill etiquette as defined by the Alpine Responsibility Code, any action that results in a collision, excessive speed, jumping unsafely, lack of awareness of surroundings, skiing backwards, not following rules, incorrect use of equipment, lack of control and other actions that could result in severe injuries 9,95–101. Using the information from the literature, guidelines from the ski hill and the Alpine Responsibility Code, the initial draft of the Risky Behaviour and Actions Assessment Tool was created 111.

Injury prevention experts, sports psychologists and industry professionals critically assessed all drafts of the tool throughout the development process and their

54 suggestions were incorporated. In addition, feedback from three separate focus groups consisting of ski patrol/instructor, parent and child skiers and snowboarders to develop a ski and snowboard safety video was also considered and integrated into the final draft of the tool (See Appendix P: Risky Behaviour and Actions Assessment Tool).

4.2.2 Determining Accuracy of the Tool

4.2.2.1 Personnel Evaluating Video and Subjects

Subjects in the video were children from grades 2 to 9 (ages 7-15) in the ski and snowboard school program at a ski area in Southern Alberta during the 2016-2017 winter season. Those who were evaluating the video included a snowboarding coach (CL), a ski instructor (SS), a ski patroller (DC) and a non-expert masters’ student (TM). These people were selected based on past ski and snowboard experience and availability.

4.2.2.2 Procedure for Evaluating Accuracy of the Tool

To evaluate the Risky Behaviour and Actions Assessment Tool, a validation process was required. There were four phases within our validation process that included obtaining video footage, followed by creation and use of video clips to assess with the tool.

The first phase was collecting video footage from the ski hills to provide an objective visual representation of behaviours seen on the ski hill while allowing the observers to view the behaviours multiple times over for verification. A video camera was set up to record video footage for 90 minutes in the beginner area at a local ski area

55 on 4 days between December 2016 and January 2017. Locations where children who were participating in ski and snowboard school programs were selected (See Appendix R:

Map For Locating Observing Sites At The Ski Area). Video footage was taken on 4 observation days based on convenience of visiting the hill for filming. After collecting all the video footage, a certified snowboard coach (SS) viewed and organized the footage into 5-15 second video clips using Microsoft Windows Movie Maker 174. Clips showing both risky and non-risky behaviours were selected. The clips’ titles included start time, end time, child identification characteristics, and number of children in the clip (See

Appendix Q: Examples of Video Clips). The snowboard coach (SS) then selected 100 clips labeled with unique identification numbers, 35 of which were deemed to exhibit risky behaviour that could be mapped back to the Risky Behaviour and Actions Tool. The video clips identified the child with descriptors and animated a circle around the child who was the focus of the clip.

The second phase involved having an experienced ski patroller (DC), ski instructor (CL) and snowboard coach (SS) view and assess risky behaviours in the video clips using the tool. Specifically, the snowboard coach (SS), ski patroller (DC) and ski instructor (CL) independently watched and rated the 100 video clips using the Risky

Behaviours and Actions Tool and entered the information on the form or directly into a

REDCap database160. The completed evaluation of each clip for risky behaviours using the tool marked the end of the second phase.

The original plan for the third phase was to create a consensus based on the evaluations of the ski patroller (DC), ski instructor (CL) and snowboard coach (SS). The consensus was originally based on all three re-watching each video with disagreements to

56 reach consensus on the types of risky behaviours seen using the Risky Behaviour and

Actions Assessment Tool. However, after a conversation with other investigators on the project, it was decided that since the snowboard coach (SS) chose the original video clips, he may have had undue influence over the final consensus, therefore his observations were not used in the consensus. Therefore, a new consensus was created based on the ski patroller (DC) and ski instructor (CL) original ratings. Specifically, the ski patroller (DC) and ski instructor (CL) re-watched each clip where they did not identify the same risky behaviour to reach consensus on what types of risky behaviours were seen using the

Risky Behaviour and Actions Assessment Tool. The two individuals then discussed their perspective with each other and came to an agreement in all cases.

In the fourth phase, a non-expert, student research assistant (RA) independently completed the Risky Behaviour and Actions Assessment Tool for each clip. The ratings from the RA were then compared with the consensus score from the ski instructor and ski patroller.

4.2.3 Reliability of Observed Risky Behaviours on Ski Hill with Inter-Rater

Assessment

4.2.3.1 Participants

Participants were children from grades 2 to 9 (ages 7-15) in the ski and snowboard school program at a ski area in Southern Alberta from schools that had agreed to be a part of our study. For the study year (2016-2017 winter season), all schools registered for the ski area school programs were invited to participate in the study by the

57 research team; 18 of the 100 schools (n=2348 students) agreed to participate. All participants were given yellow armbands to help identify which students were apart of the study group.

4.2.3.2 Procedure for Evaluating Reliability Data

The RAs followed a standard protocol of observation every time. When both observers were ready at the beginning of the observation period, they gave each other an auditory cue (e.g., “ready”). The magic carpet is a conveyor belt that pulls the participants uphill. The first student observed was the next student who came off the magic carpet with an armband. The observers discussed visual cues to make sure they were both observing the same student (e.g., “green jacket with black ski pants”). The first RA pointed out the student and described him/her before he/she went down the hill.

When the student was identified, the second RA stated when they were ready to start observing, confirmed the ID number and said: “GO”, to begin data collection. Both RAs observed the same student as the student went down the hill, and the second RA stated:

“END”, when the student was at the bottom of the run, at which time the RAs stopped observing that student. Both RAs independently assessed whether they saw any of the listed actions for each observed student. Once both RAs completed the form, they verbally confirmed they were ready for the next student and, at that point, the next student who came off the magic carpet with an armband was observed.

The ID number was based on the date and observer. Each unique ID number was consecutive for the day and each new observation day started with 1 (e.g., the day number- number of RAs present-observer (1 or 2) -ID number 1). To prevent duplication

58 of ID numbers, the observers wrote down the number of observations for each day and properly filed away all data collected as soon as they returned from the ski hill. The information from the Risky Behaviour and Actions Assessment Tool was then entered into a REDCap database160.

4.2.4 Data Analysis

4.2.4.1 Validation of the Form using Video Footage

Percent agreement and Kappa coefficients with 95% confidence intervals (CI) were calculated for the comparison of the expert consensus to the non-expert ratings 175.

Sensitivity with a 95% CI was calculated to determine the ability of the tool to correctly identify those who performed risky behaviours in a video-clip and it was based on the proportion of non-expert identified risky behaviours on the video compared with the proportion of all risky behaviours identified by the consensus using the tool. Specificity with a 95% CI was calculated to determine the ability of the tool to correctly identify those who did not perform any risky behaviours in a video-clip and was based on the proportion of non-risky behaviours identified by the non-expert compared with the proportion of overall non-risky behaviours identified by the consensus using the tool 176.

Positive and negative predictive values with 95% CIs were also calculated as the probability that subjects with an identified risky behaviour truly did engage in at least one risky behaviour and the probability that subjects without identified risky behaviour truly did not take part in at least one risky behaviour, respectively 176.

4.2.4.2 Observations of Risky Behaviour Inter-Rater Reliability

Percent agreement and Kappa coefficients with 95% CI were calculated between the two on-hill observers 175.

4.3 Results

There were 31 potential observations days where schools that were a part of our research study were at the ski area. Based on weather (n=5 days), cancellations (n=3 days), and availability of the RAs (n=13 days), there were 10 days where two RAs were able to go to the ski hill and observe students’ behaviour in the beginner area. In order to identify study participants, students of schools that agreed to participate were given yellow armbands. The original study objective was to look at both elementary and junior high students, however, due to scheduling issues the RAs were only present on days that elementary schools were at the ski hill.

4.3.1 Consensus using Video Footage

The ski instructor and ski patroller experts agreed on 81 out of the 100 videos regarding presence of risky behaviours. The ski instructor saw 11 videos with risky behaviour that the ski patroller did not agree with, and the ski patroller saw 8 videos with risky behaviour that the ski instructor did not agree with. From table 4-1, we can see the behaviours with the lowest percent agreement between the experts were cutting off (or in front of) other visitors (89.00%), other behaviours, which included not stopping while removing equipment (87.00%) and skiing too close to other visitors (86.00%). Overall, the experts initially had 81.00% agreement (Kappa: 0.57; 95%CI: 0.40-0.74).

After the ski patroller and ski instructor reached consensus, there were 33 videos classified as having risky behaviours.

Behaviour Percent Concordant Discordant Kappa 95% Confidence Landis and Koch agreement pairs pairs Intervals interpretation175 Overall Risky 81.00% 81 19 0.57 0.40 - 0.74 Moderate behaviour Visibility and Obstruction Obstructing the 98.00% 98 2 0.00 0.00 - 1.00 Poor run with other visitors present for a significant amount of time Stopping in an 97.00% 97 3 0.39 -0.15 - 0.93 Fair area on the hill that is unsafe Stopping in an 100.00% 100 0 1.00 1.00 - 1.00 Almost Perfect area on the hill where there is minimal to no visibility from uphill Hill Etiquette Cutting off (or 89.00% 89 11 0.23 -0.06 - 0.52 Fair cutting in front of) other visitors Skiing too close to 86.00% 86 14 0.63 0.47 - 0.80 Substantial other visitors

Not yielding or 91.00% 91 9 0.66 0.46 - 0.86 Substantial giving right of way to other visitors below Collision Risk Actual collision 99.00% 99 1 0.92 0.76 - 1.00 Almost Perfect with an object or person Near collision with 94.00% 94 6 0.75 0.56 - 0.94 Substantial an object or person Risk-Taking Actions Excessive speed 96.00% 96 4 0.00 0.00 - 1.00 Poor Jumping unsafely 100.00% 100 0 N/A N/A -- Skiing backwards 96.00% 96 4 0.73 0.48 - 0.98 Substantial Other Visibly unable to 91.00% 91 9 0.26 -0.08 - 0.60 Fair stop or stay in control Runaway 100.00% 100 0 N/A N/A -- equipment Skiing through 100.00% 100 0 N/A N/A -- closed off areas or trails

Other 87.00% 87 13 0.00 0.0-1.00 Poor

4.3.2 Validation of the Form using Video Footage

The non-expert RA observed risky behaviours in 25 of the 100 video clips for

86% agreement with ski patrol/ski instructor consensus (Kappa: 0.68; 95% CI: 0.52-

0.83). Relative to the consensus, the non-expert coded 8 of the videos with risky behaviours as showing non-risky behaviours and 6 of the videos with non-risky behaviours as showing risky behaviours (Table 4-2). The non-expert using the tool had

75.76% (95% CI: 57.74%-88.91%) sensitivity and 91.00% (95% CI: 81.52%-96.64%) specificity. The positive predictive value of the non-expert using the tool was 80.65%

(95%CI: 62.47%-90.16%) and the negative predictive value was 88.41% (95%CI:

78.54%-94.93%). The behaviours with the lowest percent agreement between the consensus and the non-expert were not yielding or giving right of way to other visitors below, cutting off (or in front of) other visitors and near collision with an object or person

(Table 4-3).

Table 4-2. Consensus versus non-expert determination of risky behaviour identified within 100 video clips Risky Behaviour by Consensus Risky Yes No Behaviour Yes 25 6 31 By Non-Expert No 8 61 69 33 67 100 .

Table 4-3. Breakdown of all risky behaviours identified within 100 video clips outlining the percent agreement, concordant and discordant pairs, and Kappa coefficient by a non-expert and the consensus. Behaviour Percent Concordant Discordant Kappa 95% Confidence Landis and Koch agreement pairs pairs Intervals Kappa interpretation175 Overall Risky 86.00% 76 14 0.68 0.52-0.83 Substantial behaviour Visibility and Obstruction Obstructing the run 96.00% 96 4 0.0 0.00-1.00 Poor with other visitors present for a significant amount of time Stopping in an area on 97.00% 97 3 0.39 -0.15 -0.93 Fair the hill that is unsafe Stopping in an area on 99.00% 99 1 0.00 0.00-1.00 Poor the hill where there is minimal to no visibility from uphill Hill Etiquette Cutting off (or cutting 90.00% 90 10 0.40 0.11-0.69 Fair in front of) other visitors Skiing too close to 91.00% 91 9 0.75 0.60-0.90 Substantial other visitors Not yielding or giving 85.00% 85 15 0.30 0.07-0.54 Fair right of way to other visitors below Collision Risk Actual collision with an 98.00% 98 2 0.85 0.64-1.00 Almost Perfect object or person

Near collision with an 90.00% 0.61 0.39-0.83 Substantial object or person Risk-Taking Actions

Excessive speed 97.00% 97 3 0.39 -0.17-0.94 Fair

Jumping unsafely 100.00% 100 0 N/A N/A --

Skiing backwards 96.00% 96 4 0.73 0.48-0.98 Substantial

Other Visibly unable to stop 93.00% 93 7 0.50 0.18-0.81 Moderate or stay in control Runaway equipment 100.00% 100 0 N/A N/A --

Skiing through closed 100.00% 100 0 N/A N/A -- off areas or trails

Other 88% 88 12 -0.03 -0.08 -0.01 Poor

4.3.3 Observations of Risky Behaviour Inter-Rater Reliability

There were 227 assessments done using the Risky Behaviour and Actions

Assessment Tool by two observers on elementary school students. There was 91.63% agreement for “any risky behaviour” (Kappa: 0.78; 95% CI: 0.68-0.87). The most common observed risky behaviours for both observers were skiing too close to other skiers/snowboarders and near collision with an object or person. For any risky behaviours, both observers had above 90% agreement (Table 4-4).

Table 4-4. Percent of Risky Behaviours Observed and percent agreement, concordant and discordant pairs, and Kappa coefficient with 95%CI (out of all observations with second observer [n=227]) % Agreement Concordant Discordant Kappa Landis and Koch pairs pairs Coefficient interpretation175 (95% CI) Overall Risky 91.63 208 19 0.78 (0.68 - Almost Perfect Behaviour Observed 0.87) (227) Visibility and Obstruction Obstructing the run with 99.56 226 1 0.91 (0.73 - Almost Perfect other visitors present for 1.00) a significant amount of time Stopping in an area on 96.62 220 7 0.65 (0.41 - Substantial the hill that is unsafe 0.89) Stopping in an area on 99.56 227 0 -- (N/A) -- the hill where there is minimal to no visibility from uphill Hill Etiquette Cutting off (or cutting in 97.80 222 5 0.54 (0.18 - Moderate front of) other visitors 0.89) Skiing too close to other 95.59 217 10 0.78 (0.64 - Substantial visitors 0.91) Not yielding or giving 99.12 225 2 0.00 (0.00 - Poor right of way to other 1.00) visitors below Collision Risk

Actual collision with an 98.68 224 3 0.79 (0.57 - Substantial object or person 1.00) Near collision with an 96.48 219 8 0.80 (0.66 - Substantial object or person 0.93) Risk-Taking Actions Excessive speed 97.36 221 6 0.56 (0.25 - Moderate 0.87) Jumping unsafely 100 227 0 -- (N/A) -- Skiing backwards 97.80 222 5 0.73 (0.50 - Substantial 0.96) Other Visibly unable to stop or 95.59 217 10 0.62 (0.40 - Substantial stay in control 0.84) Runaway equipment 100 227 0 1.00 (1.00 - Almost Perfect 1.00) Skiing through closed 99.56 226 1 0.00 (0.00 - Poor off areas or trails 1.00) Other 94.71 215 12 0.51 (0.28 - Substantial 0.75)

4.4 Discussion

The purpose of the Risky Behaviours and Actions Tool is to give individuals a reliable way of assessing risk-taking behaviours on the ski hill. The validation of the form was a key step in ensuring it could be used by both individuals with intensive skiing and snowboarding backgrounds and individuals with a basic background ski and snowboard knowledge.

The two experts consisted of a ski instructor and a ski patroller. The ski instructor is responsible for teaching proper technique, rules and ensuring students are practicing appropriate, non-risky behaviours. The ski patroller’s job entails promoting safety and injury prevention among skiing and snowboarding participants. The ski instructor and ski patroller had 81.00% agreement [Kappa: 0.57 (95%CI: 0.40-0.74)], reflecting moderate agreement beyond chance175.

However, we should consider that the percent agreement for individual risky behaviours from the tool varied between the ski instructor and patroller 86.00% to 100.00% with the Kappa coefficient indicating poor to almost perfect agreement. The high percent agreement with poor

Kappa score might be explained by a small number of cells within each category where the risky behaviours were seen175. When comparing the final consensus to each of the ski patroller and ski instructor ratings, both had almost perfect agreement beyond chance as expected since both effectively influenced the final consensus 175. Since there is no gold standard assessment tool, the consensus acted as a recognized measure for the comparison for the RA assessment. After evaluation of the 100 video clips, the research assistant had 86.00% agreement [Kappa: 0.68

(95%CI: 0.52 - 0.83)] with the consensus 175. This indicates that a RA with less experience with skiing and snowboarding can potentially use the Risky Behaviour and Actions Assessment Tool to evaluate risky behaviours.

When used in a real-time setting in the beginner area of the ski hill, there was 91.63% agreement between two RAs for any risky behaviour and the Kappa coefficient indicates substantial agreement 175. The Risky Behaviour and Actions Assessment Tool appears to be effective in terms of its stated aims. With this tool, researchers and other individuals interested in looking at risky behaviours have an objective tool for assessing risk taking among beginners that seems to be reliable and accurate. Future studies can use similar methods to create observational behavioural assessment tools for other sports, as at this point no observational behavioural assessments exist.

The Risky Behaviour and Actions Assessment Tool is the first objective instrument to assess risky ski and snowboard behaviours among beginners through ski hill observations.

Previous studies that have assessed risky behaviour in sport have primarily used self-reported questionnaires, which can be an unreliable and error-prone method as participants may under- report risky behaviours as a result of social desirability bias 92,93,173. The opposite might also be true for those who want to seem more deviant than they truly are (e.g., some adolescents) 177–179.

In addition, as there is no standardized method to evaluate risky behaviours, there are also no known incidence rates of evaluated risky behaviours seen through observational means within the ski and snowboard literature. To better understand how to promote safe behaviours and prevent injuries, more information is needed about the incidence and type of risky behaviours happening at the ski hill.

There were a number of limitations with this study. First, the Risky Behaviour and

Actions Assessment Tool did not contain several risky behaviours that were observed on the hill such as taking off equipment before stopping and snowboarding with one foot unbound 9,95–101,111.

Therefore, if one observer believed they saw a risky behaviour, the other may not have

71 considered it risky because it was not on the form and they may not have noticed it. As a result, risky behaviours may have been missed.

In other cases, certain risky behaviours that were originally listed on the form were not actually observed by the RA on the hill (e.g., jumping unsafely). Therefore, it might be important to evaluate which behaviours were not seen at all within this context and replace those ones with some of the behaviours that were more commonly listed under the “other” section on the Risky

Behaviour and Actions Assessment Tool.

At times, what would normally be deemed risky behaviours, such as skiing with only one pole, was a part of the lesson as an exercise done by the instructors. In these cases, when the students were following instructions, risky behaviours using the form were not evaluated, and future use of a tool should consider this if it is being used to evaluate behaviours within the context of ski and snowboard lessons. Those who use the tool in the future should be mindful of the difference between performing risky behaviours as part of following instructions in a structured lessons context, mistakes as a part of the learning process, or actual intent to take risks.

Even though we attempted to observe both junior high and elementary students, due to the scheduling conflicts we were only able to observe on days when elementary school students were present. Therefore, testing the usefulness of the tool in accurately evaluating risky behaviours in other populations is necessary in the future.

Lastly, the behaviours with the lowest percent agreement between the consensus and the non-expert were “not yielding or giving right of way to other visitors below”, “cutting off (or in front of) other visitors”, “near collision with an object or person” and the “other” categories.

Therefore, methods to increase agreement in the future should be investigated such as creating a

72 detailed manual defining all behaviours and characteristics of behaviour that can act as a guide on how to use the tool to evaluate behaviours.

4.5 Conclusion

Knowledge about the common types of risky behaviours performed by beginners on the ski hill will inform a better understanding of how to promote safe behaviours and prevent injuries. This tool can function as a method to determine the incidence of risky behaviours and the most common types of risky behaviours in a pediatric population learning to ski or snowboard. Future modifications are needed within the tool to increase precision in determining risk-taking behaviours; however, this the first behavioural assessment tool that is based on ski hill observations. Overall, the Risky Behaviour and Actions Assessment Tool is a promising instrument that can be used to assess observed behaviours in the beginner area of the hill and determine whether individuals are engaging in risky behaviours.

CHAPTER FIVE: RISKY BEHAVIOUR INCIDENCE RATES

5.1 Introduction

Skiing and snowboarding are common winter activities, especially in places such as

Alberta that have the ideal terrain and weather for snow sports 1. Recent data from the Canadian

Ski Council indicates there are approximately 2.5 million ski area visits in Alberta annually, contributing to the 78 million reported annual visits at ski hills across North America 1,2.

Participants face the potential risk of injury due to unpredictable terrain, high speeds and acrobatic nature of the activities49. With the ability to go at high speeds and perform acrobatics, partaking in risky behaviours is common and may lead to injury 49. Associated injuries range in severity from minor scrapes or overuse injuries to fatal and catastrophic trauma 165. Ski and snowboard helmets have been the focus of recommendations to reduce injury risk, but few studies have considered risky behaviour in these activities 92,7. Chamarro and Fernandez-Castro identified and assessed the perceived causes of injury events in snow sports and noted that the majority of injuries are due to poor decisions, actions, and human error 9. Analyzing the role of risky behaviours is essential for gaining a comprehensive understanding of sport injury prevention, yet it still remains an under-researched area 7.

Risky behaviour pertains to any action that has the potential to result in harm to oneself or others 80. Risky behaviour can contribute to the injury mechanism 7. Children and adolescents are considered the age group that is more likely to engage in increased risk taking and this may partially explain this age group experiencing an increase in sports injuries over the past decade 4–

6. Adolescents between 12 to 19 years old have the highest risk of injury; almost double that of any other age group. 4,5 Therefore, it is important to investigate ways to decrease injury risk

74 within dynamic activities such as skiing and snowboarding. Given the popularity of skiing and snowboarding, even small decreases in the risk can result in large public health gains. It is important to consider the role behaviour can play in reducing injuries on the ski hill.

Currently, there are no known incidence rates for risky behaviours evaluated through observational means within the ski and snowboard literature. To better understand how to promote safe behaviours and prevent injuries, more information is needed about the incidence and type of risky behaviours. The primary aim of this study was to use the Risky Behaviour and

Actions Assessment Tool to assess and determine the incidence of risky behaviours at a ski hill and determine whether the implementation of a video intervention makes a difference regarding risky behaviours seen within a child and adolescent population.

5.2 Methods

5.2.1 Study Design

This project was a part of a single blind cluster-randomized controlled trial examining the effect of a ski and snowboard safety video on knowledge, risky behaviours and injuries. The video was built on the Health Action Process Approach model, the Alpine Responsibility Code, previous literature, feedback from co-investigators, focus group research and existing evidence from ongoing local research in ski and snowboard injury prevention 180,181,61,182,163,183,91,67,184,185,63,55.

In addition, a professional multimedia company was consulted during all scripting, editing and filming phases and filmed the video. The intervention was aimed at educating children and youth about the risk of injuries and effective strategies to prevent them, while still promoting

75 participation in snow sports (for more information on development of the video intervention see Appendix C: Video Intervention Development).

5.2.2 Participants

The participants were children from grades 2 to 9 (ages: 7-16 years) in the ski and snowboard school program at a local ski hill from schools that had agreed to be a part of our study. For the study year (2016-2017 winter season), all schools registered for the ski area school program were invited by the research team to participate. In order to identify study participants at the ski area, students of schools that agreed to participate were given yellow armbands to identify them.

5.2.3 Randomization and Blinding Process

The randomization process was done a-priori and we planned to have schools stratified

(Jr. High vs. Elementary) by block randomization with block sizes of 2, 4 and 6. The research coordinator was aware of the intervention status of all schools and coordinated administration of videos and ensured all students on the hill for a particular day had the same intervention or control status. The MSc student (TM), responsible for data analysis and interpretation, and the other research assistant (RA) associated with the project were blinded to group status until all elements of data analysis and interpretation were completed and the manuscript was written.

5.2.4 Risky Behaviour and Actions Assessment Tool Development

The Risky Behaviour and Actions Assessment Tool was created to serve as an accurate and reliable way of assessing risky behaviours on the ski hill (see Appendix P: Risky Behaviour

76 and Actions Assessment Tool). The form consisted of a checklist of known risky behaviours.

This tool was developed based on known risky behaviours and risk factors identified in the literature, personal communication with experts within the skiing and snowboarding field, and focus group research. Literature identified risky behaviours such as obstructing the hill in any way, cutting off other participants, skiing too close to others, not following hill etiquette, any action that resulted in a collision, excessive speed, jumping unsafely, lack of awareness of surroundings, skiing backwards, not following rules, incorrect use of equipment, lack of control and other actions that could result in severe injuries 9,95–101. Using the information from the literature, guidelines from the ski hill and the Alpine Responsibility Code, and critical feedback from our research team the final draft of the Risky Behaviour and Actions Assessment Tool was created 111. The reliability of this form was assessed by examining the inter-rater reliability between an experienced skier instructor and patroller, comparison of their consensus with a non- expert RA and finally between two RAs (see CHAPTER FOUR: BEHAVIOURAL TOOL

DEVELOPMENT AND ASSESSMENT).

5.2.5 Observation Locations

An employee at the ski area advised the best place to observe students (see Appendix R:

Map for Locating Observing Sites at the Ski Area). Observations were made at beginner areas where there were children with yellow armbands, indicating these were students of schools that agreed to participate in our study. At times there were multiple areas for observations, as participants were in more than one area for the day. Participants were divided based on ability and age group, prior to their visit by ski area personnel. The original plan was to observe in each of the areas where students learn how to ski and snowboard starting with the areas that are for

77 more experienced children, and then transitioning to the beginner runs. However, this was not always possible as RAs needed to focus on areas with children who had armbands.

Observers were outside for 90-minute periods. If the students with armbands were present in multiple areas, the time was split up accordingly. For example, if students were only in 1 area, the observers were present for 1.5 hours at that location. When there were two eligible areas then observers divided their time into 45 minutes at each location. If students left to go to other areas and no more students with armbands were present at one location, the observers followed the children with armbands to different locations and may not have been able to divide their observation time evenly.

5.2.6 Rates of Risky Behaviours Viewed by Two Observers

5.2.6.1 Procedure for observation days with Two Observers

Observers evaluated the behaviour and characteristics of school participants using the

Risky Behaviour and Actions Assessment Tool. The same two RAs were sent out on 10 different observation days.

When both RAs were ready at the beginning of the observation period, they gave each other an auditory cue (e.g., “ready”). The first student observed was the next child that came off the magic carpet with an armband. The RAs discussed visual cues to make sure they were both observing the same student (e.g., “green jacket with black ski pants”). The first RA pointed out the student and described them before they went down the hill. When the student was identified, the second RA stated when they were ready to start observing, confirmed the ID number and said

“GO” to begin data collection. Both RAs observed the same student as they went down the hill,

78 and RA2 stated “END” when the student was at the bottom of the run, at which time the RAs stopped observing that student. Information was collected on various unsafe actions during the run using the Risky Behaviour and Actions Tool. Both RAs independently assessed whether they reported any of the listed actions by the student. Once both RAs filled out the form, they verbally confirmed they were ready for the next student and, at that point, the next student who came off the magic carpet was observed.

The ID number was based on the date, observer, and whether there was a second observer. Each unique ID number was consecutive for the day and each new observation day started with the day number - followed by the number of RAs present-observer (1 or 2) - and then the ID number in a numeric order. To prevent duplication of ID numbers, the observers wrote down the number of observations done on each day and properly filed away all data collected as soon as they returned to the Alberta Children’s Hospital from the ski hill. The information from the Risky Behaviour and Actions Assessment Tool was then entered into a

REDcap Database160. A 10% verification process was completed with all the forms completed by two observers where an RA and a research coordinator used STATA software to randomly select

22 ID numbers and then verified all the data within these forms 161.

5.2.7 Rates of Risky Behaviours Viewed by a Single Observer

Days where only a single RA was able to observe students, he/she followed the exact same protocol to assess risky behaviour (as stated in 5.2.6.1 Observations of risky behaviour inter-rater Procedure). The first subject was the next student who came off the magic carpet with an armband. As soon as the student started going down the hill, the observer started assessing the

79 student using the Risky Behaviour Assessment Tool until the child reached the bottom of the hill. The next student to come off the magic carpet with an armband was then observed. A 10% verification process was completed by an RA and a research coordinator who used STATA software to randomly select 41 ID numbers and then verified all the data within these forms 161.

5.2.8 Data Storage

Observation data were collected on paper forms and stored electronically via REDCap

(Research Electronic Data Capture) hosted at the University of Calgary. REDCap is a secure, web-based application designed to support data capture for research studies 160. Data were exported from the REDCap database and STATA 14 statistical software was used for data analysis 161.

5.2.9 Data Analysis

5.2.9.1 Sample size for observations

There is no information available on the reported rates of risky behaviours among children and adolescents on ski hills, which limited our ability to determine sample size for this study. For the sample size calculation, we cautiously assumed a minimal risky behaviour rate of

10 behaviours per 100 student-runs as a baseline rate for the control group and approximated that the video intervention will reduce risky behaviours by 50% (RR=0.5). Using the sample size formula for cluster randomized trials by Hayes and Bennett, we estimated that we would need approximately 21 clusters per arm to have over 80% power to detect a rate ratio of 0.5 162.

Therefore, we estimated that the requirement would be 42 observation days to meet the required

80 sample size of 2,436 students in each arm (total of 4,872) (refer to Appendix S: Sample size calculations for more information).

5.2.9.1 Rates of Risky Behaviours Viewed by Two Observers

Rates of the number of risky behaviours performed per 100 student runs were calculated in different covariate categories. Rates were calculated with 95% confidence intervals. The rates of risky behaviour were reported based on control or intervention group for two different

“definitions” of risky behaviour: 1. One or both observers reported any risky actions on the hill or 2. Both observers reported any risky actions on the hill. In addition, basic proportions of each type of risky behaviour were considered.

5.2.9.2 Rates of Risky Behaviours Viewed by a Single Observer

Rates of risky behaviour were defined as number of risky behaviours and actions performed per 100 student runs with 95% confidence intervals. In addition, the proportions of risky behaviours and actions were calculated. We also linked the rate and proportions of risky actions back to whether the school had the control or intervention video.

5.3 Results

Figure 5-1. Flowchart of schools and participants involved within the study

Figure 5.1 show that a total of 100 schools (12,080 students) in the area were registered in the ski and snowboard school programs at the time of recruitment for the 2016-2017 season (for entire process see Appendix M: Participant recruitment details). 80 schools were excluded due to schools and school boards not agreeing to participate, not being able to schedule the initial school visit before the outing or having students outside the age criteria. A total of twenty schools with 2728 students responded to the invitations and agreed to be part of the study.

However, 2 schools were considered lost to follow-up since a data collection session could not be scheduled in a timely manner prior to the school’s first outing to the local ski area (see

Appendix M: Participant recruitment details). The final count for potential study participants included 18 schools in the Calgary area and 2348 students who were exposed to either the intervention or control video. There were 31 potential observation days where schools that were a part of our research study were on the ski hill. Based on weather (n=5 days), cancellations (n=3 days), and availability of the RAs (n=13 days), there were 10 days where two RAs were able to go to the ski hill and observe students’ behaviour to assess risky actions using the Risky

Behaviour and Actions Tool. There were 17 additional days where the single observer could go to the ski area to observer risky behaviours.

5.3.1 Observations of risky behaviour by two observers

There were 227 observations evaluating participants using the Risky Behaviour and

Actions Assessment Tool by two observers. There was an incidence of 23.10 risky behaviours/100 runs where both observers recorded at least one risky behaviour and 24.57 risky behaviours/100 runs where either one of the observers recorded at least one risky behaviour

(Table 5-1).

From table 5-1 for the definition of risky behaviours based on whether both observers reported any risky behaviour, the incidence of risky behaviours in the control group was 29.59 risky behaviours/100 person runs, while for the intervention group, the incidence was 19.28 risky behaviours/100 person runs. If the definition of risky behaviour was defined as at least one observer viewing the behaviour, the control group had an incidence of 27.87 risky behaviours/100 person runs and the intervention group incidence was 29.52 risky behaviours/100 person runs.

The most common observed risky behaviours for both observers were skiing too close to other skiers/snowboarders and near collision with an object or person.

Table 5-1. Both versus at least one observer reported risky behaviour for inter-rater observations. Where both Where either observers reported observer reported risky behaviour, risky behaviour, n/100 person runs n/100 person runs (95%Cl) (95%Cl) Overall Risky 23.10/100 Person 24.57/100 Person Behaviour Runs (15.21- 27.53) Runs (22.49-36.99) Control Group 24.59/100 Person 27.87/100 Person Runs (13.76-40.56) Runs (16.23-44.62) Intervention Group 19.28/100 Person 29.52/100 Person Runs (13.19-27.21) Runs (21.84-39.02)

5.3.2 Rates of Risky Behaviour by a Single Observer

Table 5-2: Basic Descriptors: Sex, Activity, Proportions of Risky Behaviours, and Overall risky behaviour. Number (Proportions) Sex Male 176 (0.43) Female 125 (0.31) Unknown Sex 106 (0.26) Activity Ski 218 (0.54) Snowboard 189 (0.46) Number of risky behaviours in one ski run hill 0 312 (0.77) 1 36 (0.09) 2 28 (0.07) 3 16 (0.04) 4 12 (0.03) 5 2 (<0.01) 6 1 (<0.01) Whether there was at least one risky behaviour or not No 312 (0.77) Yes 95 (0.23)

There were 407 assessments using the Risky Behaviour and Actions Assessment Tool by one observer for an incidence of 23.10 risky behaviours/100 runs (95% CI: 15.21- 27.53). In the control group, there was an incidence of 23.31 risky behaviours/100 runs (95% CI: 16.75-29.87), and 22.95 risky behaviours/100 runs (95% CI: 17.63-28.26) in the intervention group. The most common observed risky behaviours were skiing too close to other skiers/snowboarders and near collision with an object or person in both for both groups. The control group had higher rates of these risky behaviours compared with the intervention group; however, this was not statistically significant. The maximum number of risky behaviours recorded in a single student run was six.

From table 5-3, the intervention status (control versus intervention), sex (females, males, unknown), time period in which the students were participating and time since the students watched the video did not significantly change the rate of risky behaviours.

Snowboarders engaged in a risky behaviour 1.94 (95% CI: 1.28-2.95) times more than skiers.

When comparing the intervention to the control group, those characterized as could not identify sex (unknowns) in the intervention group engaged in risky behaviours less than the unknowns in the control group (Rate Ratio: 0.32; 95% CI: 0.10-0.92; table 5-4). Those in the intervention group who had watched the video less than 8 days before their outing engaged in risky behaviours 7.00 (95% CI: 1.19-282.98) times more than those who had watched the video less than 8 days before in the control group (table 5-4).

Table 5-3. Number of Outcomes, Exposure, Rate and Rate Ratios By Each Covariate Category (Sex, Activity, Time Period, When Participants Watched The Video) Variable Number of Risky Total Runs Seen Rate (per Rate Ratio 95% CI Behaviours Seen (Denominator) 100 runs) (Numerator)

Intervention Control Status Control Group 38 163 23.31 1 -- Intervention 56 244 22.95 0.99 0.64-1.52 Group Sex Female 27 125 21.60 1 -- Male 50 176 28.41 1.32 0.82-2.10 Unknown 17 106 16.04 0.74 0.40-1.36 Activity

Ski 35 218 16.06 1 -- Snowboard 59 189 31.22 1.94 1.28-2.95 Time Period Morning 81 324 25.00 1 -- Afternoon 13 83 15.66 0.63 0.35- 1.13 How Many Days After Watching the Video Was The Group On A Ski Hill Within 7 Days 43 203 21.18 1 --- More Than 7 Days 51 204 25.00 1.18 0.79-1.77

Table 5-4. Number of Outcomes, Exposure, Rate and Rate Ratios for the Intervention Group Compared the Control Group by each Covariate Category (Males, Females, Unknown, Ski, Snowboard, <8 Days; 8+ Days). Number of Number of Rate Rate Ratio 95% CI Risky Exposures Behaviours (Denominator) (Numerator) Control Group Male 17 72 23.61 1 --

Intervention Group 33 104 31.73 1.34 0.73- 2.57 Male Control Group Female 11 58 18.97 1 --

Intervention Group 16 67 23.88 1.26 0.55- 3.00 Female Control Group 10 33 30.30 1 -- Unknown Intervention Group 7 73 9.59 0.32 0.10-0.92 Unknown Control Group Ski 24 111 21.62 1 --

Intervention Group Ski 11 107 10.28 0.47 0.21-1.01

Control Group 14 52 26.92 1 -- Snowboard Intervention Group 45 137 32.85 1.22 0.66- 2.41 Snowboard Control Group <8 Days 1 29 3.45 1 --

Intervention Group <8 42 174 24.14 7.00 1.19-282.98 Days

Control Group +8 Days 37 134 27.61 1 --

Intervention Group +8 14 70 20.00 0.72 0.36-1.37 Days

5.4 Discussion

The objective of this study was to determine the incidence of risky behaviours on a local ski hill and to determine whether these behaviours were affected by a video intervention.

Among all participants, the incidence rate at the ski area was found to be 23.1 risky behaviours/100 runs. In addition, on days with both observers, there was a rate of 23.1 risky behaviours/100 runs. The similarity between the two observers and single observer demonstrates consistency in the rates. The most common types of risky behaviours seen were skiing too close to other skiers/snowboarders and near collision with an object or person.

There were less risky behaviours in the intervention group where observers were unable to determine sex on the ski hill. This could be due to the fact that those who paid attention during the intervention video were more prepared for the outdoors, therefore more bundled up, which did not allow identification of sex. also adopting safer behaviour. There was a significant difference between the intervention and control group considering when the students watched the video. Among those who watched the video less than 8 days prior to their ski hill outing, the intervention group exhibited 7.00 times more risky behaviours than those in the control group.

However, with only one individual seen with a risky behaviour in the control group, the small sample size, wide confidence limits and the lack of control of other potential covariates and clustering by school, this finding requires a cautious interpretation.

There are limited studies on factors associated with risky behaviours in skiing and snowboarding. One study identified younger age, first time participants, higher skiing ability, male sex, and lower body mass index as characteristics related to risky behaviour in skiing and snowboarding 92. First time participants, beginners, children and adolescents, males, those with

90 improper binding adjustment or using rented equipment and snowboarding are associated with skiing and snowboarding injury 67,63,58,13,64–66. Snowboarders engaged in a risky behaviour 1.94

(95% CI: 1.28-2.95) times more than skiers, which is similar to the Sulheim et al. study that found a 2-fold greater rate of injury in snowboarders compared with skiers 63. Therefore, it might be extrapolated that injury risk is directly related to the risky behaviours within these winter sports and those who are more likely to take engage in risky behaviours are also more likely to be injured. Sex, time of day participating and when they watched the video were not risk or protective factors according to the univariate analysis.

The majority of injuries in snow sports are perceived to be due to poor decisions, actions, and human error 9. In order to gain a comprehensive understanding of how to promote safe behaviours, prevent injuries, and properly incorporate sport injury prevention strategies that can be better equipped to reduce risk in these activities, it is important to analyze the role of risky behaviours 7. This is especially true for adolescents and young adults, as they are known to take more risks than any other age groups 177,186,178. This is the first study to use a standardized assessment tool to evaluate the incidence of risky ski and snowboard behaviours and actions through observations of skiing and snowboarding children participating in the beginner area within a school sanctioned lesson program. Previous studies that have assessed risky behaviour in sport have mainly used self-reported information, which can be an unreliable method 92,93,173.

One factor that should be taken into account is that everyone has different learning strategies 121,187,188. Therefore, not all students may have been able to retain knowledge from the video, even if the intervention video lead other students to engage in less risky behaviour. Other considerations that might result in risky behaviours are peer-pressure and social deviance.

Individuals may act differently on the ski hill in front of their classmates in order to keep up

91 appearances in front of others, even if the intervention video advised against it 186. Also, the students were participating in skiing and snowboarding within a controlled, supervised environment; therefore, the supervision might have lead to students engaging in less risky behaviours 176. There is a perception that children engage in risky behaviour because they are not very good at evaluating risk or they lack safety knowledge92,7,9,99,177,178. But early research in this area demonstrated that these groups are just as good as adults at evaluating risk in a number of contexts 186,179.

There were some limitations to the project. First, not all students whose behaviour was observed on the hill may have watched their assigned video. This could be because they were absent from school when the video was shown in class, or the individual did not pay attention during their assigned video. This could indicate potential misclassification of the student’s exposure status to the intervention or control, which could lead to a diminished effect between the assigned video arm and the outcome of risky behaviour. This factor cannot be controlled as students were not directly approached on the hill and asked if they had watched the video prior to participating in lessons. In the future, determining whether students have been exposed to the entire intervention video should be measured. For the video, feedback from students should be used to provide a more precise tool for student learning and the risky behaviours seen most should be addressed in more detail.

Second, observers were unable to capture all unsafe behaviours during the designated observation period given the large size of the hill. Only the subset of children with armbands were a part of our study sample and only one child was observed at a time. Another factor that should be considered is the novelty of the Risky Behaviour and Actions Assessment Tool that was based on known risky behaviours and risk factors identified in literature, personal

92 communication with experts within the skiing and snowboarding field, focus group research and the Alpine Responsibility Code9,95–101,111. Therefore, some of the actions observed on the hill that were not listed might have been missed by both observers. However, the form has an “other” section where risky behaviours could be used. Table 5-1 shows there was a difference in the rate of risky behaviours for the intervention group depending on whether the outcome was based on data from one or two observers, which might be explained by the observers not agreeing on what

“other” types of behaviours were.

Third, the armbands on the children were difficult to view on the hill and verification processes were time consuming leading to a small sample size. Due to the poor visibility of the armbands, the next child that was viewed with an armband may not have been “next child with an armband” as they were not visible to the study team. The observers ensured that the students observed were from a school that was apart of the study by verifying the student had a yellow armband after the assessment. Therefore, better ways to identify students would have potentially increased the number of observations.

This study focused on an elementary school population within a controlled lesson environment; therefore, the incidence rate of risky behaviour calculated may be different for unsupervised skiing and snowboarding outside the school program lessons and/or for older children or those who are not beginners. Future studies should consider using the tool at the ski area to assess behaviours and ensure similar values are attained. Risky behaviours within different age groups should be investigated, as previous literature shows that young ages such as children in elementary school might engage in more risky behaviours leading to injury 92.

Finally, more evidence is needed on the effectiveness of the intervention video on the main downstream outcome of injury.

5.5 Conclusion

Through this study, the rate of risky behaviours and the most common types of risky behaviours reported on the hill among elementary students were determined through direct observation. Similar rates of risky behaviours were reported in the intervention and control groups. The most common types of risky behaviours engaged in by elementary students in the school programs were skiing too close to other skiers/snowboarders and near collision with an object or person. To our knowledge, this is the first study of risky behaviours in elementary school aged skiers and snowboarders based on ski hill observations. Future research should focus on determining whether the intervention video can reduce injuries and the rates of risky behaviour within other populations.

CHAPTER SIX: CONCLUSIONS AND FUTURE DIRECTIONS

The main aim of this project was to determine the effectiveness of a ski and snowboard injury prevention video that could be implemented as part of skiing and snowboarding school programs. The effectiveness of the video was measured in terms of safety knowledge and risky behaviours observed at the ski area in the beginner areas.

6.1 Summary of Findings

The main outcomes of this project were the effects of the video intervention on ski safety knowledge and risky behaviours.

Chapter 3 outlines the effect of the video on elementary and junior high students’ safety knowledge within the intervention and control groups. After watching the assigned video the intervention group had a statistically significant increase in change in knowledge between the pre- and immediate post-test. There was no evidence of a change in knowledge for the control group. Another finding from this study was that covariates such as grade, gender, previous experience and self-reported ability did not act as confounders or modify the effect between the video status and the change in knowledge scores. This study also demonstrated that those in the intervention group who completed the 1-month post-test had maintained their safety knowledge while those in the control group who completed the 1-month post-test did significantly better on the 1-month post-test compared with their immediate post-test. In summary, the project found that a single viewing of a skiing and snowboarding injury prevention video could improve safety knowledge in elementary and junior high students.

Chapter 4 summarizes the findings on the development and evaluation of the Risky

Behaviours and Actions Assessment Tool that was used in the beginner ski and snowboard area.

The accuracy and reliability of the tool was tested with the use of video footage, those with experience in the field and inter-rater observations at the ski area. The validation process included having a ski patroller and instructor and one non-expert evaluating risky behaviours in video clips. The non-expert had 86.00% percent agreement with the ski patroller-instructor consensus. The reliability of the Risky Behaviours and Actions Tool was assessed directly at the ski hill by two non-expert observers. The two observers had a 91.63% percent agreement and a

Kappa score of 0.78 (95% CI: 0.68 - 0.87) representing substantial agreement beyond chance.

After these evaluations, the Risky Behaviours and Actions Tool was deemed an accurate and reliable tool that could be used as a standardized method for observational assessment of behaviours and actions among beginners at a ski area. Developing a tool is important and necessary within injury prevention research to allow for an objective way to determine the most common types of risky behaviour and the incidence of these behaviours seen at the ski hill.

Chapter 5 reports the incidence of risky behaviour observed in the beginner areas of the ski hill in relation to video status of participants. This study demonstrated that there was no significant difference in the overall observed rate of risky behaviours between the video intervention and control group. Snowboarders engaged in risky behaviours at a rate 1.94 (95%

CI: 1.28-2.95) times greater than skiers. The most common types of risky behaviour observed were skiing too close to other skiers/snowboarders and near collision with an object or person.

The rates of risky behaviours were 23.31 risky behaviours/100 runs (95%CI:16.75-29.87) in the control group, and 22.95 risky behaviours/100 runs (95%CI:17.63-28.26) in the video intervention group. This was the first study to determine rates of risky behaviours through

96 observational means in the beginner areas of a ski and snowboard hill using the novel Risky

Behaviours and Actions Assessment Tool.

Due to the anonymous nature of the on-hill risky behaviour evaluation, the behaviour and knowledge outcomes cannot be combined to determine the overall effect of the video on the adoption of safe behaviours through increased knowledge.

6.2 Strengths and Limitations

6.2.1 Study Design

A single blind, cluster-randomized controlled trial study design was used to mitigate the effect of multiple potential biases. First, the use of blinding guarded against the research assistant’s preconceived notions influencing the effect of the video. Precautions such as labeling group A and group B throughout the entire study were necessary for concealing intervention group status. The master’s student (TM) and RA did not have access to school names and video status of any group until the final analysis and interpretation of data were completed. Second, the use of clustering takes into account that students within the same classroom and school may be more similar in their knowledge and act a certain way compared with students from different classes/schools would 176. Clustering students within their class considers the fact that the variance within classes might be smaller than that of students between classes. For the knowledge data, the smallest unit we could cluster by was class. Third, the advantages of using a randomized controlled trial include the ability to examine the influence of the intervention video on knowledge outcomes directly after viewing the video where it is unlikely that both measured and unmeasured potential confounders could have influenced outcomes. This may not be true for

97 the assessment of risky behaviours as there were external factors such as potentially more safety education before participating, too much time since the students watched the intervention video or warnings from teachers and instructors about unsafe actions within the ski area.

6.2.2 Attrition

Out of the 1034 potential participants, only 251 completed the 1-month follow up knowledge questionnaire; 129 (19.9%) from the control group and 122 (32.5%) from the video intervention group. However, comparing all the participants to the students who completed the 1- month post-test, there were similar proportions of students in each grade, gender, experience and self-reported ability in both the control and intervention group. Therefore, it is less likely that there was a selection bias operating between those who could have completed the 1-month post- test compared with those who actually did complete the 1-month post-test. In the future, consent to contact individuals by phone or sending reminder emails might result in better follow up completion.

6.2.3 Behavioural Assessment Form

The use of the Risky Behaviour and Actions Assessment Tool was an objective way to determine the incidence of risky behaviours in the beginner area of the ski hill. Previous literature has focused on self-reported risky behaviours by participants, which could lead to an underestimation in rates of risky behaviours reported as individuals may not want to admit to behaving in ways that are against the rules and regulations at ski areas, which might result in severe consequences 92,93. Using an objective, standardized tool provides researchers and other individuals interested in evaluating risky behaviours a way to collect information about

98 behaviours on the ski hill without adding the potential for misclassification bias due to self- reporting.

6.2.4 Generalizability

This study was based on an elementary and junior high student population who were participating within school lessons programs at a ski area in Southern Alberta. Participants in grades 2 to 9 completed the knowledge pre- and post-tests and there is no known reason that the data could not be extrapolated to other children and adolescents within grades 2 to 9 with similar curricula. For the rates of risky behaviours, only elementary students were observed on the hill during instructed lessons (due to scheduling of the RA and other factors covered in chapters 4 and 5). While this limits the generalizability of the findings, literature states that risky behaviours and injury risk is higher in younger and first-time participants 13,189,190. However, the observed rates of risk behaviours may not represent the incidence rates for adolescent populations, adults, or younger students who are not participating in school programs.

6.2.5 Knowledge and Behaviour Outcome

Education is a common strategy to help prevent injuries 10. Literature dictates that children who were injured while participating in skiing and snowboarding either lacked safety knowledge or were not following the rules of the ski hill, which suggests that prevention of injuries might be done successfully by education and proper knowledge translation that can lead to adoption of safer behaviours 99. This project does not allow us to tie together the effects of knowledge and behaviour from the video intervention. Students were not identified on the hill and we could not match a student’s knowledge change score to their behaviour on the hill. In addition, multiple studies have stated that child and adolescent populations may still engage in

99 risky behaviours and actions regardless of knowing better 85,177,186. Multiple factors might affect behaviours seen on the hill (e.g., ability, peer-pressure) and it should be noted that this project was done within the controlled environment of a ski and snowboard lesson program at beginner areas of the hill.

Due to multiple factors that might have affected behaviour and the chance students may have been given more instruction or materials on ski hill safety after being shown the videos, we cannot attribute changes in risky behaviours back to the video status of the students. Future projects should identify students after their ski hill run and then tie their behaviour back to their knowledge assessment scores after watching their assigned video to better determine if the video had a direct effect on risky behaviours and actions.

6.3 Future Directions, Recommendations and Conclusions

This research demonstrates that a skiing and snowboarding injury prevention video can improve knowledge scores successfully within an elementary and junior high population. Yet overall, the video intervention was not associated with the incidence of risky behaviours seen within school program participants in elementary school. Future research in injury prevention should investigate how to better translate knowledge to induce behavioural changes and limit risky behaviours among skiers and snowboarders. More concrete information is needed about how knowledge and behaviour are associated and the direct effect of a video intervention on behaviour. Future research should consider measuring how knowledge change scores are associated with risky behaviours seen on the ski hill. In addition, both knowledge and behavioural outcomes should be linked to injury data from the ski area to determine if the video intervention could be associated with reducing the number of injuries seen within the ski area

100

(even in the absence of no reduction in the rates of risky behaviours). The long-term goal includes measuring injuries in both the video intervention and control group. Should the video intervention reduce injuries, then implementation of the intervention video as a tool used for youth could be done at ski areas provincially and nationally. This will ideally reduce the number of injuries and, if successful, lead to a decrease in the number of ED visits and lower the healthcare costs for treatment and rehabilitation of ski and snowboard injuries.

101

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APPENDICES

123

Appendix A: Search Terms for Literature Review

SEARCH TERM TABLES (APPROVED BY LIBRARIAN):

Columns will be combined with the word: OR The final concept columns will combined and then Rows with the word: AND

Appendix A 1: Search Terms general injury information Concept A (Outcome) Concept B (prevalence) Concept C Concept D (Sport) (population) Knowledge* prevalence Ski Pediatric* Behaviour incidence Snowboard Children* Behaviour change* Burden of Injury Ski* Child* Action* Economic cost Snowboard* Adolescent* Social costs Snow Sport* Economic* Winter Sport* Epidemiolog* Cost of illness* Costs.mp. Cost.mp. Injury rate*

Appendix A 2: Search terms for safety knowlegde Concept A (Outcome) Concept B Concept C (Prevention) (Sport) Knowledge* safety Ski Behaviour management Snowboard Behaviour change* Ski* Action* Education Snowboard* Dangerous Action* Educat* Snow Sport* Safety Management Winter Sport* Safety education Accident Prevention knowledge Health Knowledge, Attitudes, Practice safety knowledge Learning

Appendix A 2: Search Terms for behaviour and risk taking Concept B Concept C (Prevention) (Sport) Knowledge* Risk* Ski Behaviour Risk Factor* (both MeSH and keyword) Snowboard Behaviour change* Protective Factor* (both MeSH and keyword) Ski*

124

Action* Equipment Snowboard* Dangerous Action* Protect* Snow Sport* Sports Equipment (MeSH) Winter Sport* Head Protective Devices Prevent*.mp. Risk Reduction* Risk Reduction Behavior Risk Factor Surveillance System Risk Assessment Risk-Taking Risky actions risk compensation theor* Behaviour theor*

Appendix A 4: Search terms for interventions Concept A (Outcome) Concept B Concept C (Prevention) (Sport)

Behaviour* Primary prevention (MeSH and keyword – truncate terms for Ski keyword) Knowlegde* Program evaluation (MesH and keyword – truncate for Snowboard keyword) Attitude* Injury prevention Ski* Belie* Injury prevention program Snowboard* Action* Prevent* [kw] Snow Sport* Safe* Intervention* Winter Sport* Implement* Evaluation discover the subject heading for this – evaluat* will search evaluation as a keyword Evaluat

* Adapt * Uptake

Program* Video* Intervention* Information intervention* Early Intervention Brochure* Pamphlet*

Embase

125

Medline Scopus SPORTDiscus

Behaviour Search Strategy ovid

Database: Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid MEDLINE(R) <1946 to Present> Search Strategy: ------1 exp Skiing/ (3318) 2 exp Snow Sports/ (3445) 3 ski.mp. (3044) 4 snowboard.mp. (158) 5 snowboard*.mp. (571) 6 exp Behavior, Animal/ or behaviour.mp. (383732) 7 exp Risk Factors/ or exp Risk Reduction Behavior/ or risk*.mp. or exp Behavioral Risk Factor Surveillance System/ or exp Risk/ or exp Risk Management/ or exp Risk Assessment/ (2373822) 8 exp Risk Factors/ or exp Risk Reduction Behavior/ or risk*.mp. or exp Behavioral Risk Factor Surveillance System/ or exp Risk/ or exp Risk Management/ or exp Risk Assessment/ (2373822) 9 exp Risk-Taking/ or risky actions.mp. or exp Choice Behavior/ (84005) 10 exp Head Protective Devices/ or risk compensation theory.mp. or exp Risk Assessment/ (241436) 11 risk taking.mp. or exp Risk-Taking/ (35454) 12 dangerous actions.mp. (43) 13 exp Dangerous Behavior/ or dangerous behaviour.mp. (4104) 14 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 (2772451) 15 1 or 2 or 3 or 4 or 5 (5389) 16 14 and 15 (815) 17 pediatric.mp. or exp Pediatrics/ (283893) 18 exp Child Behavior/ or exp Child/ or child.mp. (2066325) 19 17 or 18 (2156658) 20 16 and 19 (187)

***************************

Knowledge

126

13 exp Safety/ or exp Health Knowledge, Attitudes, Practice/ or safety knowledge.mp. or exp Safety Management/ (168598) 14 exp Learning/ or learning.mp. (522548) 15 10 or 11 or 12 or 13 or 14 (1957616) 16 pediatric*.mp. (300822) 17 exp Child/ (1891738) 18 exp Adolescent/ or exp Child/ (2972132) 19 16 or 17 or 18 (3069358) 20 9 and 15 (570)

***************************

Intervention:

***************************

Child intervention

Database: Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid MEDLINE(R) <1946 to Present> Search Strategy: ------

127

1 exp Skiing/ (3318) 2 exp Snow Sports/ (3445) 3 ski.mp. (3044) 4 snowboard.mp. (158) 5 snowboard*.mp. (571) 6 snow sport.mp. (17) 7 snow sport*.mp. (185) 8 exp Snow Sports/ or winter sport*.mp. (3626) 9 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 (5553) 10 pediatric*.mp. (300822) 11 exp Child/ (1891738) 12 exp Adolescent/ or exp Child/ (2972132) 13 10 or 11 or 12 (3069358) 14 intervention*.mp. or exp "Early Intervention (Education)"/ (865162) 15 video*.mp. or exp Video-Audio Media/ (137183) 16 brochure.mp. or exp Pamphlets/ (4848) 17 knowledge.mp. or exp Knowledge/ (640390) 18 exp Patient Education as Topic/ or video intervention*.mp. (84609) 19 14 or 15 or 16 or 17 or 18 (1617778) 20 9 and 19 (423) 21 13 and 20 (112)

Intervention and knowledge and behaviour:

Database: Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid MEDLINE(R) <1946 to Present> Search Strategy: ------1 exp Skiing/ (3318) 2 exp Snow Sports/ (3445) 3 ski.mp. (3044) 4 snowboard.mp. (158) 5 snowboard*.mp. (571) 6 snow sport.mp. (17) 7 snow sport*.mp. (185) 8 exp Snow Sports/ or winter sport*.mp. (3626) 9 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 (5553) 10 pediatric*.mp. (300822) 11 exp Child/ (1891738) 12 exp Adolescent/ or exp Child/ (2972132) 13 10 or 11 or 12 (3069358) 14 intervention*.mp. or exp "Early Intervention (Education)"/ (865162) 15 video*.mp. or exp Video-Audio Media/ (137183) 16 brochure.mp. or exp Pamphlets/ (4848) 17 knowledge.mp. or exp Knowledge/ (640390) 18 exp Patient Education as Topic/ or video intervention*.mp. (84609) 19 14 or 15 or 16 or 17 or 18 (1617778) 20 9 and 19 (423) 21 knowledge.mp. or exp Knowledge/ or exp Health Knowledge, Attitudes, Practice/ (640390) 22 exp Safety/ or exp Accident Prevention/ or safety knowledge.mp. or exp Safety Management/ (77786) 23 exp Behavior, Animal/ or behaviour.mp. (383732) 24 exp Child/ or exp Adolescent/ or exp Child Behavior/ or child behaviour.mp. (2975951) 25 exp Risk-Taking/ or risk compensation theory.mp. or exp Risk Assessment/ (269283)

128

26 exp Risk Factors/ or exp Risk Reduction Behavior/ or risk*.mp. or exp Risk/ or exp Risk Management/ or exp Risk- Taking/ or exp Risk Assessment/ (2377088) 27 exp Risk Factors/ or exp Risk Reduction Behavior/ or risk*.mp. or exp Risk/ or exp Risk Management/ or exp Risk-Taking/ or exp Risk Assessment/ (2377088) 28 dangerous actions.mp. (43) 29 exp Learning/ or learning.mp. (522548) 30 21 or 22 or 23 or 24 or 25 or 26 or 27 or 28 or 29 (6060397) 31 20 and 30 (250)

***************************

EMBASE Database: Embase <1980 to 2017 Week 01> Search Strategy: ------1 exp Skiing/ (4463) 2 exp Snow Sports/ (398) 3 ski.mp. (3651) 4 snowboard.mp. (183) 5 snowboard*.mp. (608) 6 snow sport.mp. (23) 7 snow sport*.mp. (73) 8 exp Snow Sports/ or winter sport*.mp. (574) 9 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 (6679) 10 exp Education/ or education.mp. (1465961) 11 exp Safety Management/ or safety education.mp. or exp Accident Prevention/ (549001) 12 knowledge.mp. or exp Knowledge/ (654065) 13 exp Safety/ or exp Health Knowledge, Attitudes, Practice/ or safety knowledge.mp. or exp Safety Management/ (626081) 14 exp Learning/ or learning.mp. (546632) 15 10 or 11 or 12 or 13 or 14 (2885747) 16 pediatric*.mp. (419843) 17 exp Child/ (2505382) 18 exp Adolescent/ or exp Child/ (3175594) 19 16 or 17 or 18 (3285949) 20 9 and 15 (1171) 21 19 and 20 (335)

***************************

Knowlegde intervention

Database: Embase <1980 to 2017 Week 01> Search Strategy: ------1 exp Skiing/ (4463) 2 exp Snow Sports/ (398) 3 ski.mp. (3651) 4 snowboard.mp. (183) 5 snowboard*.mp. (608) 6 snow sport.mp. (23) 7 snow sport*.mp. (73)

129

8 exp Snow Sports/ or winter sport*.mp. (574) 9 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 (6679) 10 exp Education/ or education.mp. (1465961) 11 exp Safety Management/ or safety education.mp. or exp Accident Prevention/ (549001) 12 knowledge.mp. or exp Knowledge/ (654065) 13 exp Safety/ or exp Health Knowledge, Attitudes, Practice/ or safety knowledge.mp. or exp Safety Management/ (626081) 14 exp Learning/ or learning.mp. (546632) 15 10 or 11 or 12 or 13 or 14 (2885747) 16 pediatric*.mp. (419843) 17 exp Child/ (2505382) 18 exp Adolescent/ or exp Child/ (3175594) 19 16 or 17 or 18 (3285949) 20 9 and 15 (1171) 21 19 and 20 (335) 22 intervention*.mp. or exp intervention study/ or exp early intervention/ (1025783) 23 exp education/ or video intervention*.mp. (1383113) 24 video*.mp. (144877) 25 exp questionnaire/ or exp patient education/ or brochure.mp. (676620) 26 pamplet.mp. (1) 27 22 or 23 or 24 or 25 or 26 (2761423) 28 20 and 27 (542) 29 19 and 28 (187)

130

Appendix B: Letter from Winsport

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Appendix C: Video Intervention Development

Previously, there has been no consistent or comprehensive injury prevention program developed or implemented in the context of school sanctioned ski and snowboard programs at

Winsport. The need for this type of resource has been expressed by members of the ski industry

(Appendix __ - WinSport reference letter), and having such an injury prevention tool will address many aspects of safety in these popular activities. This project focused on implementation and evaluation of a comprehensive ski and snowboard injury prevention program using a video intervention. The intervention was aimed at educating children and youth about the risk of injuries and effective strategies to prevent them, while still promoting participation in snow sports. Given the popularity of skiing and snowboarding, even small decreases in the risk can result in large public health gains. The video was developed with input from injury prevention experts and industry professionals and incorporated content and format suggestions based on three rounds of ski patrol/instructor, parent and child skier and snowboarder focus group feedback. In addition to this, to produce a high quality video a professional multimedia company was consulted during the scripting, editing and filming phases.

The development of the video intervention consisted of 3 phases, each involving multiple focus groups.

The first phase consisted of exploring pre-understandings, relevant content, potential delivery methods, and format of the injury prevention educational video and development of the storyboard. Within this phase, we considered the use of behavioural theory models, which are relatively new in the realm of sports injury prevention 191; however, behavioural theory models have been applied in other domains of health promotion and have been shown to be successful 88.

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Although a number of different theories aim to predict the uptake of new health associated behaviours, the development of the video intervention was focused on models that include predictors of behaviour maintenance because continued or repeated use of prevention measures is necessary to maintain a protective effect. The Health Action Process Approach (HAPA) is a behavioural maintenance model that was used as the theoretical foundation of the video intervention in order to create a tool with measurable, evidence-informed pathways to behaviour change and maintenance in children 145. According to the model, task self-efficacy, maintenance self-efficacy, available resources can predict long-term adherence to injury prevention behaviours, and identify potential barriers to continued participation, as well as intention to engage in the behaviour (Figure 1). The model has been used to successfully predict adoption and maintenance of health behaviours in a number of general populations, and has shown early promise in predicting injury prevention behaviour in youth sport settings 145,159,192,193. Building on this model, previous literature, feedback from co-investigators, focus group research and existing evidence from ongoing local and robust research in ski and snowboard injury prevention, as well as current literature, we developed an initial storyboard 55,61,63,67,91,163,180–185. The ThinkFirst Canada and the National Ski Areas Association videos are slightly out-dated and require revising in terms of the scientific evidence on ski and snowboard injury prevention or specifically target terrain park participants. Due to the lack of a current video that covers up to date safety information and has a built in injury prevention component, we aimed to create a new video; In addition, the video developed was specified for the Canada Olympic Park and Winsport ski and snowboard school program participants. However, the previous videos mentioned along with the

Alpine Responsibility Code can provided a good basis for understanding some of the important guidelines for participation within these winter activities (Canada, T. A Little Respect... at

133 http://www.thinkfirst.ca/programs/a_little_respect.aspx); Association, N. S. A. Smart Style. at http://www.nsaa.org/safety-programs/smart-style/) 111. Using the information found, a visual storyboard was created that outlines options for each scene which: (Appendix B) identified risks and possible outcomes (e.g. not wearing a helmet and head injury); strategies to help viewers change behaviour (e.g. demonstration of where to buy a helmet and how to properly fit it), and; what to do about unexpected circumstances (e.g. forgot helmet at home, strap on helmet breaks).

Once injury prevention experts evaluated the storyboard, it was then assessed by three separate focus groups consisting of child skiers and snowboarders, their parents, ski patrollers and other ski hill staff for feedback. The feedback was critically assessed and added to the storyboard, which was again evaluated by the injury prevention experts to create the finalized storyboard.

The completion of the storyboard was the end of the initial phase of the video development.

The second phase of video development involved writing a script. Using the storyboard, what is known currently within the skiing and snowboarding literature and feedback from the first focus groups, a script was developed based on the storyboard. Once a draft of the script had been created, a second focus group series consisting of children involved with ski and snowboard, parents of those children, ski patrollers and other ski hill staff evaluated the script before filming. The moderator of the focus group introduced the script and provided copies to each participant. The focus group participants were asked to comment on each scene individually and in a group discussion. The feedback from this session was incorporated into the script. The injury prevention experts then evaluated the final script to ensure that all components of the script were feasible. The final script was for used in filming the ski and snowboard injury prevention video.

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In the third phase, the first cut of the film was created and feedback was obtained through another focus group session. The goal of this final session was to obtain detailed focus group feedback from the participants about the messaging, in order to produce a video intervention that would maximize the potential to promote the adoption of ski and snowboard safety behaviours. The entire film was shown to the focus group at once and then participants were asked for feedback individually followed by a group discussion. In addition to the feedback on the messaging of the film, participants were asked to list the themes to assess comprehension of the film. A quiz was given both before and after this last focus group session to ensure that the key safety messages were conveyed. Once all the feedback was incorporated, input from injury prevention experts and industry professionals was needed in order to verify the requirements for the final video. Finally, professional guidance from the film company was required to help develop a high quality product. The final video created is available in DVD format, and on a secure website.

Using the feedback from the focus groups through the entire video development process allowed the production of a final version that contains all the relevant current evidence in ski and snowboard injury prevention, and that is tailored to the school ski and snowboard program audience.

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Figure C-1. Diagram of Health Action Process Approach (HAPA) Model

Reference: Schwarzer R. Modeling health behavior change: How to predict and modify the adoption and maintenance of health behaviors. Appl Psychol. 2008;57(1):1–29.

Adapted from schwarzer with permission.

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Appendix D: Ski and Snowboard Safety Video Script

Ski and Snowboard Safety Video Storyboard

1 Time: Less than 10 minutes

Summary: This video will cover important safety points related to skiing and snowboarding. The primary audience will be school-aged children who participate in ski and snowboard school programs at Canada Olympic Park. This video will discuss preparation for the ski hill, proper equipment, and the Alpine Responsibility Code.

CHARACTERS:

MALE 1-A 6th to 8th grader (open to older ages as well).He is passionate about snowboarding and wants to become amazing at it like his favourite PRO. He is also popular amongst his peers with a good sense of humour.

FEMALE 1- A 6th to 8th grader. She is kind and intelligent, as well as careful and thorough. She likes to try new things (such as skiing) because she knows that she can learn and grow a lot from the experience. She also likes to be well prepared and to expect the unexpected.

MALE 2 -A 6th to 8thgrader. He’s interested in learning how to ski (mostly because it’ll get him out of school).

FEMALE 2- A6th to 8thgrader. She wants to learn more about snowboarding and has a carefree and adventurous spirit. She iscalm, cool and collected. Knows what to do in stressful and urgent situations.

*TEACHER. The TEACHER accompanies the students on the trip.

SKI INSTRUCTOR 1 AND SKI INSTRUCTOR 2. Calm, cool and amicable individuals.The epitome of reassuring and supportive instructors. They are always there to show the kids the ropes and answer their questions. The instructors also look out for the safety and well-being of their students and always emphasize safety first. They can be found wearing teal blue jackets.

*SKI PATROLLER - Ski patrollers wear red jackets with white crosses on them. They patrol and ensure the safety of the hill.

TECH - Confident and helpful. Takes pride in ensuring that visitors receive exceptional service and equipment that fits their needs in the best way possible.

NOTE: Improvisation is welcome.

Scene 1: INTRODUCTION

1 The length of the safety video can be perceived as a HAPA barrier to self-efficacy, Children have short attention spans and therefore may not be as likely to pay attention to safety messages if they are bored. Therefore we will attempt to address this barrier by keeping the video short and sweet, and also make it more appealing for the audience.

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EXT. COP

It is a calm and sunny morning on the ski hill (slow EDM or trance music plays in the background). We see ski patrol setting up the ski hill with markers, barriers, and signs that inform skiers and snowboarders of the hill conditions for the day.

Music transitions over to more energetic music. Clips are shown of skiers and snowboarders on the ski hill doing various activities: on a lift, run, and terrain park. GoPro footage is shown from the point of view of skiers and snowboarders who are going down various runs in a safe and controlled way.

MALE (voice over): I woke up today so excited that I jumped out bed ready for a new adventure. You see, today 2 was not just any other day. It was my first day hitting the slopes. My first ski and snowboard trip.

Scene 2: PREPARATION

INT. CLASSROOM

MALE 1 snaps out of day dream after FEMALE 1 friend calls out to him.

FEMALE 1: Nice day huh. Perfect for our trip to the hill. Are you excited for the field trip?

MALE 1: I am so pumped! I got plenty of sleep last night, had a nice healthy breakfast to stay energized, and packed a nutritious lunch.

FEMALE 1: I brought water and snacks for us to eat during breaks so that I won’t get hungry during lessons. You seem warm and ready to go.

MALE 1: Yeah, I’m wearing the layers and materials that were recommended. I’ve got a thin insulating pair of thermal underwear as my base layer, a light fleece or down layer as my mid layer, and my waterproof winter jacket and snow-pants as my outer layer to stay dry and warm when we’re outside since I dislike feeling cold and wet. I also put sunscreen on my face.

The words BASE LAYER, MID LAYER, and OUTER LAYER shown on screen with a popup image of different layers on screen as MALE 1 explains the different layers.

3 FEMALE 1: I borrowed ski clothes from my cousin. Luckily we are the same size! I didn’t own thermal underwear though, so I wore leggings as my base layer. Just as long they aren’t jeans since they get cold and wet more easily.

2 As per HAPA, in order to motivate students (especially during the pre-intentional phase), one of the primary goals of the video would be to get kids excited about learning to ski and motivate them to stay safe on the hill. The introductory scene and MALE 1 voice over (cool shots of tricks, people having fun on hill, etc.) are meant to encourage action self-efficacy from HAPA (“where an individual does not yet act, but develops a motivation to do so”)

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MALE 1: I brought my own goggles too so that I can protect my eyes. I made sure they were all packed in my 4 bag last night so that I wouldn’t forget them.

FEMALE 1: And thick socks, those are important too! I brought an extra pair of socks and mitts, just in case my 5 first pair gets wet.

MALE 2 and FEMALE 2 walk up to them.

FEMALE 2: Come on guys, our teacher is handing out our lift tickets and progression cards, we’re going to need those.

FEMALE 1, FEMALE 2, and MALE 2 walk towards their TEACHER.

MALE 1: Here we go.

MALE 1 follows friends.

EXT. SCHOOL LOADING ZONE

STUDENTS are lining up to leave their school and head over to COP.

6 FEMALE 1: But you know what though? As much fun as it looks, I’m a little nervous.

MALE 2 (reassuringly): Well that’s part of the fun isn’t it. Sure there are risks, as there are with any sport, but I think the fun and physical activity will outweigh the risk. Also, we are getting good instruction and will learn how to 7 be safe. I’m personally just excited to not have another day stuck in a classroom.

3 This specific moment can also be interpreted as a solution for students who may not be able to afford ski and snowboard gear (providing that fit is not compromised). Not being able to access and afford proper gear and equipment for snow-sports can be a barrier to learning how to ski and snowboard safely and to feel motivated.

4 Decided to include packing your equipment the night before as some kind of coping strategy to overcome the barrier in case they forget to bring some safety equipment.

5 This can also be a solution or planning strategy. Wet clothes and socks can be uncomfortable when learning to ski or snowboard, so one way that students can overcome this is to bring extra pairs of dry socks (or pants).

6 FEMALE 1’s worry about learning how to ski for the first time is meant to coincide with the risk perception aspect of HAPA (risk perception = one’s contemplation or perception of consequences and competencies)

7 This comment by MALE can be interpreted as coping or maintenance self-efficacy featured in the HAPA model. It represents one’s optimistic beliefs about one’s capability to deal with barriers that arise during the maintenance

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Scene 3: Arrival and getting equipment at the rental shop.

EXT. COP ENTRANCE

Quick exterior shot of COP and WinSport day lodge (a few seconds).

INT. COP DAY LODGE – CAFETERIA

Shots of the STUDENTS entering the cafeteria inside the day lodge and sitting at tables.

SKI INSTRUCTOR 1 approaches a table with the STUDENTS.

SKI INSTRUCTOR 1: Hi guys! I’ll be one of your instructors for the day. Who’s ready to have fun?

STUDENTS at the table erupt into cheers.

SKI INSTRUCTOR 1: Alright, alright, I like your enthusiasm! The first thing we’ll do is set up your gear. Follow me!

Shots of STUDENTS getting up from their tables and following their SKI INSTRUCTOR 1 down to the rental shop.

INT. RENTAL SHOP

Shots of rental shop activities are shown. MALE and FEMALE students are waiting in line outside of rental shop. MALE 1 gets called in next.

TECH: Hi! What’s your shoe size?

MALE 1 shows the TECH his lift ticket, which has a sticker with his height, weight and shoe size. TECH picks out a pair and hands snowboard boots to MALE 1.

TECH: Alright buddy, try these ones on for size.

MALE 1 demonstrates the proper way to put on snowboard boots while FEMALE 1 demonstrates putting on ski boots.

SKI INSTRUCTOR (voiceover): When putting on your boots, there should only be your feet and one layer of socks inside, and no tucked in snow-pants. Your boots should be snug and have little foot movement inside, but be comfortable.

MALE 2 and FEMALE 1 line up to get their skis.

TECH: Hey, here is a quick lesson on your bindings. Bindings are meant to release in order to prevent injury. That’s why it’s very important to have your bindings adjusted for weight and ability by a certified technician, preferably at the start of each season.

MALE 2 and FEMALE 1 pick up their equipment with properly adjusted bindings.

MALE 1 lines to up to pick up his helmet.

phase. MALE 2 is essentially keeping the snow-sport experience positive by assuring that they are in good hands a controlled environment in order to be able to learn how to ski and snowboard safely and successfully.

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TECH: When it comes to snow sports, you have to wear the right helmet. So no bicycle helmets. *Clip of person wearing a bicycle helmet with an X over it*. Or hockey helmets. *Clip of person wearing a hockey helmet with an X over it*. It has to be a helmet made specifically for skiing or snowboarding.

TECH: When looking for good helmet fit, remember to follow the “2-V-1” rule. “2” fingers should fit above your eyebrows. A “V” should be formed by your straps or ear pads under your ears. And “1” finger should fit between your chin and strap. *Screen shows “2”, “V” and “1” corresponding with each point as they are demonstrated* You want a helmet that is not too tight but not loose when you move. You can adjust the fit of the helmet straps if you need to. So let’s give these a go first. And remember, no toques or hats underneath as they can affect helmet fit.

Camera zooms in on proper helmet fit parts on MALE 1 that correspond to the 2V1 rule.

MALE 2 tries putting on his helmet while wearing a pom-pom hat, but the result shows poor helmet fit. MALE 2 sighs and takes off his pom-pom hat before putting on his helmet again. He tests out his helmet fit again using 2-V-1 and gives a thumbs up when it’s right.

SKI INSTRUCTOR: Alright, now you are ready to conquer the hill. Stay safe and have fun.

Panning shot of fully and properly equipped skier/snowboarder (split screen showing MALE and FEMALE characters with their properly fitted equipment, with the occasional zoom in to parts of the equipment that demonstrate good fit).

FEMALE 1: Sweet, thanks!

FEMALE 1 and TECH fist bump.

STUDENTS pick up their skis or snowboard and follow their SKI INSTRUCTOR to the hill now that their equipment is ready. STUDENTS reach the carpet outside and put on their skis and test out their bindings.

Scene 4: Environment/Respect the mountain

EXT. COP, BEGINNERS AREA

MALE and FEMALE characters split up into their appropriate group and follow their SKI INSTRUCTORS outside to COP. STUDENTS look to their SKI INSTRUCTORS, bright eyed and eager to start their first lesson.

SKI INSTRUCTOR 2: Welcome to your first lesson: getting used to your environment and becoming aware of your surroundings.

STUDENTS look around them, absorbing their surroundings, such as where people are and what they’re doing, etc.

SKI INSTRUCTOR 2: One of the most important things to know on the hill is how to stay in control. *Word “CONTROL” shows up on screen* If you are worried about not being able to stay in control, you can slow down or 8 stop if you make your skis into a pizza or snowplough position, or turn your skis or snowboard across the hill.

8 This is an example of action planning from HAPA. Action planning is when there is a specific action in place

(“How”) when there are specific situation parameters (“when”, “where”) or barriers. In this case, we are providing examples of what riders can do (“How”) if they are having difficulty staying in control (“when”, “where”).

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*Examples shown on screen of students slowing down using snowplough/pizza, and turning skis or snowboard 9 across the hill while SKI INSTRUCTOR 2 is explaining them. *

Some students gently fall to the ground, but do not appear to be hurt.

SKI INSTRUCTOR 2: Great job you guys! Remember that falling when skiing and snowboarding is NORMAL and happens to everyone. Even the pros fall and just get up right away and carry on. Only get up though when you’ve 10 come to a complete stop and with your skis or snowboard pointing across the hill

SKI INSTRUCTOR 2 shows students how to recover after falling (don’t try to get up until you come to a complete stop and only get up with your skis pointing across the hill). Show snowboarders falling and getting up whilst wearing wrist guards.

SKI INSTRUCTOR 2: If you guys plan to continue to snowboard, wrist guards are a great piece of equipment to 11 consider since they protect your wrist in case you fall.

Clips of SKI INSTRUCTOR 2 giving one-on-one help to students and helping them correct their technique. Eventually SKI INSTRUCTOR 2 is impressed with their progress and nods in approval.

SKI INSTRUCTOR 2 (voiceover): If you’re going on a run, make sure you know the difficulty level before you go on it. You can find them on maps of the hill. Green circles mean beginner, blue square is intermediate, and black diamond is expert. Since this is our first day, we will be staying on green circle runs.

As the ski hill difficulty marking system is explained by the SKI INSTRUCTOR 2, a map of COP is shown on screen and symbols for each difficulty level is shown as they are explained: green circle=beginner, blue square=intermediate, black diamond=expert.

9 This is an example of the volition phase from HAPA (which is a post intentional phase where it leads to actual health behaviours). In this case it is when the students finally learn how to ski/snowboard, but they learn to do so safely and in control.

10 Here we are trying to reinforce that falling is NORMAL in snow-sports and change risk perception. It is really important for students to perceive falling as NORMAL and ACCEPTABLE when skiing and snowboarding, so that they don’t feel discouraged as they are learning. This can also address recovery self-efficacy, wherein they learn how to get up and keep going right away as a way to recover from falling. For maintenance self-efficacy, it is important to be positive and encouraging in lessons so that students can have more optimistic beliefs about their ability to get better at skiing and snowboarding, even if they fall several times.

11 Wearing wrist guards can also be a coping planning strategy, where in the anticipation of falling while learning a new sport, wearing a wrist guard can protect riders from seriously hurting themselves.

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SKI INSTRUCTOR 2: It’s a good idea to only go on harder runs when you are more experienced and have control over your speed and turns. Even if you’re an intermediate rider, try warming up on an easier run first.

SKI INSTRUCTOR 2: If you find yourself on a run beyond your ability level or if there are conditions you aren’t comfortable riding in, try going slower to stay aware and in control. *Show on screen someone riding down the terrain very slowly in the proper snowplough position.*

SKI INSTRUCTOR 2: Make sure that you continue to give way to other skiers and avoid hitting people below you. 12 If you’re really struggling though, ask for help from someone who is experienced.

SKI INSTRUCTOR 2: Warning signs and boundaries are put up for a reason: for safety and to inform everyone of dangers in the area. It is very important to obey all signage on the hill.

Show shots of people slowing down near patches of ice or areas that aren’t groomed and have very little snow.

SKI INSTRUCTOR 2: Make sure that you’re aware of your surroundings and are comfortable with your environment. Keep an eye out for hazards and avoid them.

Show an example of a skier carefully avoiding an environmental risk (a piece of snowmaking equipment sticking out of the snow).

Scene 5: Others on the hill/Respecting Others

EXT. COP, BEGINNER AREA

In this scene, SKI INSTRUCTOR 2 explains hill etiquette for when they are in the beginner area with additional riders and for when they go on other hill runs in the future.

SKI INSTRUCTOR 2: All right guys, I’m going to explain to you all how to be safe when you are on a hill with other skiers.

SKI INSTRUCTOR 2: Hill runs can get busy, and if people don’t follow the rules of the hill, it will be really dangerous for everyone. That’s why it’s especially important for you to be prepared on the hill and aware of the people around you so you react accordingly and ride defensively. Keep looking around for other hazards too, and 13 make sure you’re not one either.

Cut to an area on the side of the hill where it is safe for the students and instructor to stand and where it easy for others to see them.

12 This is another example of action planning from HAPA. Action planning is when there is a specific action in place

(“How”) when there are specific situation parameters (“when”, “where”) or barriers. In this case, we are providing examples of what riders can do (“How”) in situations where the hill run or terrain is too challenging for them, or if they are having difficulty staying in control (“when”, “where”).

13 This is another example of risk perception from HAPA. There are opportunities for collisions and accidents on the ski hill, and it is important for riders to follow safe practices on the hill.

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SKI INSTRUCTOR 2: Now, when you are sharing the hill with other skiers and snowboarders, you are expected to ’Know the Code’. The Alpine Responsibility Code. *”ALPINE RESPONSIBILITY CODE” is shown on the screen* It contains 10 points that help keep you and everyone else on the hill safe. You can find them posted around the hill on big yellow signs.

Shots of the yellow Alpine Responsibility Code sign are shown around the lodge with the occasional skier or 14 snowboarder stopping to look at the signs.

SKI INSTRUCTOR 2: If you are ever uncertain about hill safety, just remember these basic points. Avoid going too fast, always stay in control -

Clip shown of someone going too fast down the hill and falling over.

SKI INTRUCTOR 2: -and give everyone plenty of space on the hill.

Two skiers are skiing next to each other, one skier gets TOO CLOSE to the other and ALMOST collides with them (zoom in on how tight the space is between them). Two skiers show that they are relieved when they are further 15 apart from each other and have more room to ski.

SKI INSTRUCTOR 2: When you’re on a busy run, it’s really easy to get a little too close to others. Whether it’s from going too fast, cutting people off without checking first, or stopping in the middle of the hill or an area where 16 you are not visible. We recommend stopping in an area off to the side that is not beneath the dip of a hill.

Clips of skiers and snowboarders performing these different violations as the SKI INSTRUCTOR 2 explains them.Scene of a collision from violating these principles. Clip freezes and points show up one at a time of the 17 different violations that were made that led to the collision.

SKI INSTRUCTOR 2 (voiceover): You are expected to give the right of way to people BELOW you and yield to them. So if you encounter that, slow down a little behind, check that there’s space and that the area is clear before passing them. It is also important to check uphill for people coming downhill and not to make sudden moves or direction changes.

14 Showing where the Alpine Responsibility Code is posted can be a coping planning strategy and address barriers where riders may not be able to remember all of the safety points and may need a visual reminder.

15 This is an example of a negative outcome expectancy, which is demonstrating the outcome that would be expected if a dangerous behaviour was performed on the hill, such as skier too close to someone which can increase the likelihood of collision.

16 HAPA action planning strategy for how to make the hill safer for yourself and others (although it’s not always in your control if not everyone follows the rules of the hill).

17 This is another example of a negative outcome expectancy, which shows the different hill violations that led to the collision.

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Clips are then shown of what you SHOULD do instead as SKI INSTRUCTOR 2 is explaining them (with the occasional clip from the POV of the skier/snowboarder for realism): giving the right of way to people below you and yielding to them (slow down a little behind them, check that there’s space and that the area is clear before passing them), checking uphill and your surroundings constantly for people coming downhill and not making sudden moves or changes in direction, giving plenty of space to everyone and not skiing too close to people (safety cushion).

One of the FEMALE characters demonstrates good places to stop: at the side of the hill where skiers above can see (i.e. not just below a dip in the hill). FEMALE demonstrates checking uphill at merging trails and cutting across hill 18 while staying in control and not going too fast.

Some STUDENTS are eventually shown reaching the bottom of a run or carpet safely.

Transition to clips of various lifts leading to different runs.

SKI INSTRUCTOR 2 (voice over): Beginners going up a lift for the first time should always go up with an adult. Make sure that you are physically able to load and unload from the chairlifts. Make sure that your skis or snowboard stay on your feet when doing so (or at least have one foot attached to your snowboard). Put the safety bar down once you and everyone else is loaded and ready. Lift the safety bar up near the top of the hill. There will be a sign on a chair lift tower indicating when to lift up the bar. If you are nervous or uncertain about how to use a chair lift safely, ask an attendant. They will help you get on the lift.

Clips shown of STUDENTS, INSTRUCTORS and other patrons safely getting on and off a chairlift while SKI INSTRUCTOR 2 is explaining what to look out for.

SKI INSTRUCTOR 2: When you’re on a chairlift, make sure that your pole tips are pointing forward and your pole straps are off your wrists. When loading and unloading, keep your ski tips pointing upward or your snowboard facing forward.

SKI INSTRUCTOR 2: We are all capable of being safe on the hill. If we look around for other people and hazards and follow the rules, we can all be safe, which makes it more fun for everyone. With enough practice, these 19 behaviours will become natural.

Scene 6: Peer pressure and doing dangerous things beyond ability level

EXT. COP, BEGINNER AREA OR PROGRESSION CARPET

MALE 1 and FEMALE 2 look at other older snowboarders go down the hill quickly and skillfully and with ease. MALE 1 and FEMALE 2 look at them pass by with awe.

MALE 1: Wouldn’t it be cool if someday we could be as good as them?

FEMALE 2: It would be. We have a long way to go though before we can get to that level.

18 This is an example positive outcome expectancies from HAPA. Wherein following proper hill etiquette leads to a safer hill for others and no loss of control or risk of collision.

19 This is meant to help students feel more encouraged and to create a more positive perceived self-efficacy in all of the students so that they believe that can become really great at skiing and/or snowboarding over time.

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Further down the side of the hill, a RANDOM SNOWBOARDER does a straight-line move, whizzing straight down the hill. MALE looks in awe.

20 Male 2: Hey dude, why don’t you give it a go.

MALE 1: Oh I don’t know-

Male 2: Come on, where’s your sense of adventure. Try and keep up with the big boys.

MALE 1: Well, it would be sweet if I pulled it off. I can really impress people.

MALE 1 puts himself in position to try the move. Knees bent, head low. He pumps himself up, takes a deep breath, and starts moving down the slope. He is ecstatic that he is going so fast and seems to have successfully accomplished the move. However, he realizes that he’s going too fast, loses control and he wipes out (and potentially crashes into another skier or snowboarder on the hill). Cut to a clip of MALE 1 sitting in a chair at home or the ski patrol medical examination room shaking his head at his wrist or ankle wrapped up and iced thinking 21 “Well that was a stupid idea”. Back to reality, the wipeout was just a daydream. MALE 1 shakes his head.

MALE 1: On second thought, maybe you’re right, I think it’s too risky to try that when I still need to master the basics

Male 2: Suit yourself man, see ya!

Male 2 glides away.

FEMALE 2: You did the right thing. You shouldn’t feel pressured to do something you are not ready to do. It is more important to put your safety and the safety of others first. Now, having the courage to say no, that is impressive.

MALE 1: I guess you’re right.

Male 2 tries to snowboard towards the entrance to the terrain park. SKI INSTRUCTOR cuts him off and stops in front of Male 2, blocking entrance to the terrain park. Male 2 sighs and turns around and snowboards away from the terrain park.

SKI INSTRUCTOR 1: The terrain park is a cool place to check out after you master the basics, but it is important to be very experienced first and to only go in when you are absolutely ready.

20 This situation can be perceived as a barrier to safe behaviour: being peer pressured into doing techniques or tricks that students may not be comfortable doing or be ready for.

21 Attempting to do tricks that a student may not be ready for can also be an example of risk perception from

HAPA wherein it is important for students to have an accurate perception of their ability level. This is also meant to be a coping planning strategy for how to address peer pressure. In this case it is teaching students that it’s okay to say no in peer pressure situations and that there can be negative consequences or outcomes to doing techniques beyond their ability level.

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Scene 7: What to do in an emergency

STUDENTS are practicing more in the beginners’ area near the end of the day.

MALE 2: Man I don’t know about you, but I feel like I am getting the hang of this. But what if something bad happens when we aren’t in a lesson?

SKI INSTRUCTOR 1 approaches them.

SKI INSTRUCTOR 1: That is very important to know. What did you learn?

FEMALE 1: Well first of all, always ski with a buddy and always have a plan. *Words “HAVE A BUDDY” and “MAKE A PLAN” show up on screen*. A plan with a place and time to meet up, especially if you don’t know the area very well. That way in case you get separated from your group or your ski buddies, you’ll be able to find each other again and know that they’re safe. If you do get separated from your group, the most important thing to 22 remember is don’t panic and stay calm. When in doubt, meet at the bottom of the lift you just went up.

MALE 2: Yeah, but what are you supposed to do if you get hurt?

As if on cue, someone nearby wipes out and appears to have injured their leg. FEMALE STUDENT 2 skies up to the INJURED PERSON.

Female 2: Are you okay? Do you need my help?

INJURED PERSON nods their head.

Female 2 stops a nearby student.

Female 2: Hey you, can you please go find ski patrol? Or tell a lift attendant to contact ski patrol? We have an injured leg here halfway up in the beginner area, near the right side.

STUDENT nods and skis off. NARRATION from SKI INSTRUCTOR 1 voices over as Female 2 makes sure that STUDENT is as warm and comfortable as possible.

SKI INSTRUCTOR 1 (voice over): If you see someone who is hurt, don’t leave them alone. Make sure they are warm and comfortable but don’t move them. Stay with them and get someone else to notify ski patrol or a lift attendant or an instructor.

SKI PATROL (red jackets) are notified and ski to beginner area where injured person is. FEMALE 1 and MALE 2 are impressed and stare in awe.

Scene 8: Conclusion

STUDENTS are shown packing up their equipment, returning their gear to the rental shop, and loading back onto the bus.

MALE 1and FEMALE 1 are in line to load back up onto the bus.

22 This is an example of action planning from HAPA. This will give students an idea of what they can do BEFORE they go on their trip to ensure that they don’t get separated from their group.

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They get on the bus and sit down, laughing and chatting about the fun they had that day.

MALE 1 (voice over, interspersed with clips of highlights from their ski day): I realized that when you’re learning to ski and snowboard with your friends, it’s not about becoming the best of the best or learning the tricks, it’s about being safe towards yourself and others to avoid getting hurt. While I only learned the basics today, with enough practice I can eventually be great. Best of all, the real take away from my ski and snowboard trip is just having fun 23 with my friends.

Clips of skiers and snowboarders having fun on runs and in beginner area. Final message shown on screen is “BE SAFE. HAVE FUN”. END. Fade out.

23 This voiceover from MALE 1 is meant to demonstrate the positive outcome expectancies from HAPA. That the most important takeaway message or outcome of their trip is to have fun with their friends and to have made progress from not knowing anything about skiing or snowboarding at all in the beginning.

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Appendix E: Cover Letter for Ethics

March 23, 2016

Dear Conjoint Health Research Ethics Board,

We are pleased to submit our ethics application for “Ski and Snowboard School Programs: A safety video intervention for behavioural changes, knowledge uptake and preventing injuries in school- aged children ”, for consideration as research study for the winter 2016-2017 skiing and snowboarding season. This is a clustered randomized control trial study of the effects of a video intervention on children aged six to fifteen years who participate in the ski and snowboard school programs at WinSport’s Canada

Olympic Park (COP). We hope to show that a new video can aid in increase knowledge uptake, decrease risky behaviour and reduce injury risk for children participating in skiing and snowboarding.

A number of ethical considerations must be taken into account for this project as it entails working with children but we feel that we have addressed all major issues. Firstly, we will get consent from parents and assent from children who are over the age of 7 who understand what the study entails.

Risks to participants exists in the realm of privacy of data as we will be collecting all the Accident Report

Forms from WinSport over the 2016-2017 skiing and snowboarding season, which have confidential and private information. Our research team will take all necessary steps to ensure that data remains secure and privacy is maintained. For the risky behaviour assessment we will be picking random dates and sending research assistants to observe behaviour during the skiing and snowboarding lessons. This entails minimal risk to participants for this study as it is observation and in order to ensure safety all research assistants will have background and police checks. According to the University of Calgary Ethics, it is assumed that electronic submission of the questionnaire implies informed consent to participate in the study. Therefore, if the parents and children take the time to do the 10 minute questionnaire and watch the video and answer the post-test questions they have agreed to be a part of our study. We do not see additional risks or adverse events due to participation in this study. We feel that our project is ethically sound and potential

149 benefits of the study will include creation of a successful injury prevention component that can help reduce injury risk, increase safety knowledge and decrease risky behaviour in children participating in skiing or snowboarding which can be used for a number of years to come.

Sincerely,

Tatum Priyambada Mitra, BKin BSc C4-344 Alberta Children’s Hospital 2888 Shaganappi Trail NW Calgary, AB, Canada T3B 6A8 [email protected]

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Appendix F: Ethics Certificate/ Ethics Approval

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EB Certification File: The effect of a safety video on ski and snowboard school program participants in (REB15-

Calgary, Alberta 0749)

Formal Title: Ski and snowboard Legacy File Number:

school programs:

Assessing the effect of

a safety video

intervention on

knowledge, behaviour

and injury risk in youth

skiing and

snowboarding

Submission Type: Graduate Student – Thesis, Dissertation, Capstone Project.

Principal Investigator: Brent Hagel Approving Board: CHREB

Primary Admin Contact(s): Maya Djerboua Certificate of

Approval:

Original Approval Date: July 26, 2016 Letter of Approval:

Last Approval Date: July 26, 2017 Expiration Date: July 26, 2018

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Appendix G: Consent Form

TITLE: Ski and Snowboard School Programs: A safety video intervention for behavioural changes, knowledge uptake and preventing injuries in school-aged children.

PRINCIPAL INVESTIGATORS: Dr. Brent Hagel & Dr. Carolyn Emery

This consent form is only part of the process of informed consent. It should give you the basic idea of what the research project is about and what your child’s participation will involve. If you would like more detail about something that is mentioned here, or information not included here, please ask. Take the time to read this carefully and to understand any accompanying information. You will receive a copy of this form.

BACKGROUND Skiing and snowboarding are the most common winter activities. The Canadian Ski Council indicates there are roughly 2.5 million ski area visits in Alberta annually. Skiing and snowboarding are known as two of the leading causes of injury in pediatric populations and participation is associated with a high risk of injury. Currently, we do not have an injury prevention component built into ski and snowboard school programs.

WHAT IS THE PURPOSE OF THE STUDY? We aim to develop, implement and evaluate a comprehensive injury prevention program which can be used by the ski and snowboard school programs that can help increase safety knowledge, decrease risky behavior and reduce injury risk on the slopes. By having a comprehensive injury prevention component in these programs, it will allow new skiers and snowboarders to learn how to minimize risk, and carry this forward as they continue participating in these winter sports in the future. In addition, limiting the number of injuries may increase continued participation in skiing or snowboarding. Evaluating the effectiveness of this intervention, we will help develop ski area school program protocols that can be used at other ski areas provincially and nationally to help prevent injuries. WHAT WOULD YOU BE EXPECTED FROM YOU? Your participation is completely voluntary and you can decide to not take part or to stop at any time. This study will involve two different parts. Firstly, we will ask you and your child to fill out some demographic data. Your child will be asked to do a survey of 10 questions (we ask that you

153 do not help with any of these questions). Then their will be a 10 minute video that your child will be asked to watch and then your child will answer another 10 questions (we ask that you do not help with any of these questions). The questions will take about 5-10 minutes. The second part of the project will look at how the effects of the video intervention on safety on following skiing and snowboarding trips. We will ask you to complete a survey one month after the initial visit to the ski hill.

WHAT ARE THE RISKS? There are no risks associated with participating in this project. All the information collected from the project will be kept private and confidential.

ARE THERE ANY BENEFITS FOR ME? There are no direct benefits to participating in this project. The information collected may help us to prevent injuries and deter dangerous behaviour on the ski-hill in the future.

DO I HAVE TO PARTICIPATE? Please note that your family is not required to take part in this project. You can refuse to answer any or all of the questions. The care you and your family receive will not change if you choose to not be part of this project or answer any of the questions.

WILL MY INFORMATION BE KEPT PRIVATE? All information will be kept private and confidential. Your name and contact information will be removed as soon as the second part of the project is completed. Only the project team and the University of Calgary Conjoint Health Research Ethics Board can see each person’s data. When we share findings of the project, all information will be grouped in a way that no one can be identified.

WILL WE BE PAID FOR PARTICIPATING, OR DO WE HAVE TO PAY FOR ANYTHING? We will not pay you to participate and you do not have to pay us to participate.

IF I OR MY CHILD INJURE MYSELF DURING THE STUDY, WILL WE BE COMPENSATED? If you suffer an injury as a result of participating in this research, no compensation will be provided to you by the WinSport Academy, the University of Calgary, the Alberta Health Services or the Researchers.You still have all your legal rights. Nothing said in this consent form alters your right to seek damages.

SIGNATURES

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Your signature on this form indicates that you have understood to your satisfaction the information regarding your child’s participation in this study and agree to your child’s participation. In no way does this waive your legal rights nor release the investigators, or involved institutions from their legal and professional responsibilities. You are free to withdraw your child from the study at any time without jeopardizing their health care. If you have further questions concerning matters related to this research, please contact:

I consent for my child, ______to participate. Child’s Name (please print)

______Parent/Guardian’s Name (please print) SignatureDate

______Investigator/Delegate’s Name (please print) SignatureDate

The University of Calgary Conjoint Health Research Ethics Board has approved this research study.

A signed copy of this consent form has been given to you to keep for your records and reference.

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Appendix H: Assent Form

TITLE: Ski and Snowboard School Programs: A safety video intervention for behavioural changes, knowledge uptake and preventing injuries in school-aged Children.

PRINCIPAL INVESTIGATORS: Dr. Brent Hagel & Dr. Carolyn Emery

Skiing and snowboarding are the most common winter activities and can be lots of fun. But, sometimes when you are skiing or snowboarding you can get injured. We want to do everything possible to ensure you are safe and know how to avoid dangerous situations on the slopes. Therefore, we are creating a video on safety that will show you how to be safe on your ski/snowboard trip and as you continue participating in these winter activities.

What will I have to do?

If you agree to participate in this project you will be asked to:

You and your parents will tell us about your age, school and if you have been skiing or snowboarding before. Answer a couple of questions about what you know about ski and snowboard safety and hill protocol Watch a 10 minute video after answering the questions Answer a couple of questions about what you know about ski and snowboard safety and hill protocol after you have watched the video One month after your ski-visit to Canada Olympic Park/WinSport, we are going to email you and ask you some questions about experience and if you have gone on another outing.

What are the risks? There are no risks associated with participating in this project and all personal information collected will be confidential and will not be shared with anyone outside of the project team.

Will being part of the project help me?

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There are no direct benefits to you or your family for participating in this project. However, the information collected may help us create a video that covers all the important things that everyone need to know to be safe on the hill and stop risky actions.

Will people find out about me because I am part of this project? All personal information will be kept private and will not be shared with anyone outside of the research team.

Do I have to participate?

No. You do not have to be part of this project if you do not want to be. No one will be upset with you. If you have any questions at any time, please ask! You can also stop participating at any time.

If you have any other concerns, you can contact the Principal Investigators:

Would you like to be in this project?

___ Yes ___ No

______Child’s name Signature of the child Date

______Investigator/Delegate’s Name Signature Date

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Appendix I: Invitation to Schools For Participant Recruitment

For schools from Calgary Catholic School District:

Dear Principal [name],

I am part of a research team at the University of Calgary studying injury prevention in youth sports and we are partnering with WinSport for a study on ski and snowboard school programs. We learned from the school programs manager at WinSport that your school has registered for the ski and snowboard school program this upcoming 2016/2017 season. We would like permission from you, the principal at [school name], to recruit students to participate in this study. Please find attached to this email a description of our proposed research study. The data that will be collected and used in this study will be kept private and confidential. We will also not be asking the students to perform anything unsafe or harmful. Members of the research team will only directly contact teachers and parents of the students, and not the students themselves. We also recognize and respect the

Catholic School District’s wish to not further burden teachers beyond their everyday responsibilities. The research team will ensure that there is minimal class disruption and burden to the teachers during data collection. We are hoping that the findings from this study will lead to a safer environment for students when they go skiing or snowboarding with their school.

We have been granted ethics approval for this study from the University of Calgary Conjoint Health Research Ethics

Board and the Calgary Catholic School District Research Committee (please see attached letters). We would greatly appreciate a reply to this email indicating your permission for your school’s participation. Study participation is also voluntary. Please do not hesitate to contact me if you have any questions. Thank you for your kind attention.

Sincerely,

Maya Djerboua

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For all other schools:

Dear Principal [name],

I am part of a research team at the University of Calgary studying injury prevention in youth sports and we are partnering with WinSport for a study on ski and snowboard school programs. We learned from the school programs manager at WinSport that your school has registered for the ski and snowboard school program this upcoming 2016/2017 season. We would like permission from you, the principal of [school name], to recruit students to participate in this study. Please find attached to this email a quick overview of our proposed study. The data that will be collected and used in this study will be kept private and confidential. We will also not be asking the students to perform anything unsafe or harmful. Members of the research team will only directly contact teachers and parents of the students, and not the students themselves.

Permission to conduct this study was given by [name of respective school board] (please find attached the approval letter). We have also been granted ethics approval for this study by the University of Calgary Conjoint

Health Research Ethics Board (please find attached the ethics approval letter). We would greatly appreciate a reply to this email indicating your permission for your school’s participation. Study participation is also completely voluntary. Please do not hesitate to contact me if you have any questions. Thank you for your kind attention.

Sincerely,

Maya Djerboua

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Appendix J: Infographic Inviting Schools to Participate

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Appendix K: Invitation to Parents and Students for Participant Recruitment

Interested in improving ski and snowboard hill safety?

We are a research team at the University of Calgary Sports Injury Prevention Research Centre and we are interested in improving ski and snowboard safety in children and adolescents with an educational video tool. You are receiving this invitation because your school has given us permission to invite students from your school who ski or snowboard to participate in this study. If you agree to participate, you will be asked to complete a 15 minute survey, and you (or your parents) will be emailed a video link and a follow-up survey approximately one to two weeks before your school field trip to the ski hill.

If you participate in ski and snowboard activities at your school and are interested in this study*, please copy the survey link below or scan the QR Code:

[insert link and QR code]

For more information, please contact:

Maya Djerboua 403-955-7765 [email protected]

*Deadline to register by: October 31, 2016. Please ask your parents first before you participate.

This study has been approved by the University of Calgary Conjoint Health Research Ethics Board (Ethics ID: TBD) and the Calgary Board of Education, Calgary Catholic School District, and Rocky View School District Research Committees (ID: TBD).

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Appendix L: Infographic of Process Involved within Study for Schools

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Appendix M: Participant Recruitment Details

Participant recruitment began with obtaining the school program lesson schedule and list of participating schools from the school programs manager at the local ski area. A total of hundred schools (12080 students) in the area were registered in the ski and snowboard school programs at the time of recruitment. Three high schools (55 students) were automatically excluded on the basis of being outside of the age criteria, leaving behind only elementary and junior high schools (97 schools and 12025 students).

School boards and districts were then contacted for research approval to approach elementary and junior high schools for study recruitment. Twenty-four schools (3019 students) were ineligible since their affiliated school board did not give the research team their permission to recruit participants from within their district. This included private schools with their own independent approval process. Permission was not received from select school boards and private schools mostly due to a lack of response, although one school board did indicate that the reason for their refusal was because the study did not fulfill the school board’s language requirements. One private school also indicated that the proposed research was not a good fit for their curriculum since they limit screen use and electronic devices during school lessons.

Seventy-three schools and 9006 students had permission at the school board level and were eligible for study participation. Initial study invitations were emailed to the principals and vice-principals of each eligible school (see Appendix A for a written example of the study invitation). Principals from nineteen schools responded to the initial invitation, and 8 refused participation while twelve agreed to be a part of the study. An email reminder was sent to the remaining schools approximately one month after the initial invitations were emailed out. Upon

165 sending the follow-up email, six principals and school representatives agreed to their school’s participation in this research, while twelve schools declined.

The fifty-three remaining schools who did not respond to the initial and follow-up emails received telephone calls from the research team to gauge their study interest. The remaining schools were left voicemail messages. After the phone call follow-ups, two schools with 170 students agreed to participate in the study, while three schools (121 students) declined.

Follow-ups with schools on a weekly basis did not continue if a response was not received and a data collection session was not scheduled one week prior to the school’s first outing to the ski area. Based on this follow-up criteria, thirty schools (3810 students) were excluded.

A total of twenty schools with 2728 students responded to the invitations and agreed to be part of the study. However, three schools were considered lost to follow-up since a data collection session could not be scheduled in a timely manner prior to the school’s first outing to the local ski area.

The final count for study participants included seventeen schools in the Calgary area and 2348 students were exposed to either the intervention or control status (see Appendix B for a complete recruitment flowchart).

Out of the 53 schools who were eligible but chose not to participate in the study:

• 30 schools (56%) gave no response and could not be included in the study. • 7 schools (13%) declined study participation due to being busy with school engagements and other studies and initiatives. • 1 school (2%) declined study participation due to lack of feasibility (e.g. lack of resources, time, etc.) • 12 schools (23%) declined study participation with no reason given.

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• 3 schools (6%) declined study participation because their school was no longer a part of the ski and snowboard school program.

Figure 3-1. Flowchart of schools and participants involved within the knowledge part of study

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Figure 5-1. Flowchart of schools and participants involved within the behaviour part of study

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Appendix N: Detailed Procedure Knowledge and Behaviour

N1. Participants:

The project was set up through a partnership between the University of Calgary Sports

Injury Prevention Research Centre and Winsport based on the need of information on safety knowledge and how to better protect children on the ski hill from injuries and other preventable events. Winsport allowed the research team to contact all the schools once the project had ethics and permission from the appropriate school boards.

A total of 100 schools (12080 students) in the area were registered in the ski and snowboard school programs at the time of recruitment for the 2016-2017 season. Three high schools (55 students) were automatically excluded on the basis of being outside of the age criteria, leaving behind only elementary and junior high schools (Ninety-seven schools and

12025 students). School boards and districts were then contacted for research approval to approach elementary and junior high schools for study recruitment. Twenty-four schools (3019 students) were ineligible since their affiliated school board did not give the research team their permission to recruit participants from within their district. This included private schools with their own independent approval process. Permission was not received from select school boards and private schools mostly due to a lack of response, although one school board did indicate that the reason for their refusal was because the study did not fulfill the school board’s language requirements. One private school also indicated that the proposed research was not a good fit for their curriculum since they limit screen use and electronic devices during school lessons.

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A total of twenty schools with 2728 students responded to the invitations and agreed to be part of the study. However, 2 schools were considered lost to follow-up since a data collection session could not be scheduled in a timely manner prior to the school’s first outing to the local ski area. The final count for study participants included 18 schools in the Calgary area

2348 students were exposed to either the intervention or control video. 1 School with 46 students did not complete pre and post-test for the knowledge portion of the study. Out of the 2302 students from 17 schools who were exposed to an assigned, parental consent and assent was attained 1034 students.

N2. Detailed Knowledge Procedure:

The knowledge assessments were developed by injury prevention experts, the winsport partners, ski patrollers, instructors, in addition to previous literature about ski and snowboard safety. Questions about preparations, equipment and proper hill etiquette were included in the knowledge assessment questionnaire (see Appendix O for pre- and post-test knowledge assessments). The pre- and post-test knowledge assessment questionnaire was pilot tested by the research team in a final round of child focus groups related to video development before the school programs commence in the 2016-2017 winter season for face validation.

A research coordinator was sent to the classrooms to ensure that all classes had the same data collection process. The research coordinator explained to the students that they would be answering some questions, watching a video and then again answering questions, and these would not be marked however we wanted them to try as best as possible to answer all the questions. At the start of the data collection session demographic information was collected at the school and individual level, followed by a pre-test knowledge assessment for students to complete independently (for pre-test see Appendix O). Students took this baseline safety

170 knowledge assessment before watching the assigned intervention or control video (pre-test) and the after watching the video took the same test immediately after watching their video (post- test). A follow-up assessment test was sent to the participants 1 month after watching the video and attending their first school outing to complete again independently.

Unique ID were assigned to each participant based on school and grade. Once paper forms of the pre and post test were collected, the documents were properly filed away as soon as they returned from the school. The information from pre and post tests were then entered into a

REDcap Database160. A 10 percent verification process was completed where a research assistant and a research coordinator used STATA software to randomize 110 ID numbers and then verified all the data within these forms 161.

N3. Detailed Behaviour Procedure:

There were 31 potential observations days where students from schools that were a part of our research study were on the ski hill. There were 10 days where two research assistants were able to go to the ski hill and observe students’ behaviour. While on 17 days, at least one research assistant went out on the ski hill.

In order to identify study participants, students of schools that agreed to participate were given yellow armbands.

The RAs followed a standard protocol of observation every time. When both observers were ready at the beginning of the observation period, they gave each other an auditory cue (e.g.,

“ready”). The first student observed was the next student that came off the magic carpet with an armband. The observers discussed visual cues to make sure they were both observing the same student (e.g., “green jacket with black ski pants”). The first RA pointed out the student and described him/her before he/she went down the hill. When the student was identified, the second

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RA stated when they were ready to start observing, confirmed the ID number and said:

“GO”, to begin data collection. Both RAs observed the same student as the student went down the hill, and the second RA stated: “END”, when the student was at the bottom of the run, at which time the RAs stopped observing that student. Both RAs independently assessed whether they saw any of the listed actions for each observed student. Once both RAs completed the form, they verbally confirmed they were ready for the next student and, at that point, the next student who came off the magic carpet with an armband was observed.

Days where only a single RA was able to observe students, he/she followed the exact same protocol to assess risky behaviour (as stated in the inter-rater procedure). The first subject was the next student that came off the magic carpet with an armband. As soon as the student started going down the hill, the observer started assessing the student using the Risky Behaviour

Assessment Tool until the child reached the bottom of the hill. The next student to come off the magic carpet with an armband was then observed.

The ID number was based on the date and observer. Each unique ID number was consecutive for the day and each new observation day started with (the day number- number of

RAs present-observer (1 or 2) -ID number 1). To prevent duplication of ID numbers, the observers wrote down the number of observations for each day and properly filed away all data collected as soon as they returned from the ski hill. The information from the Risky Behaviour and Actions Assessment Tool was then entered into a REDCap database160. A 10 percent verification process was completed where a research assistant and a research coordinator used

STATA software to randomize 40 ID numbers and then verified all the data within these forms

161.

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Appendix O: Pre and Post-Test Assessment for Student Participants

Ski and Snowboard Survey

This survey usually takes about 10 minutes to complete. Sections B and C are to be completed by the student only. Please answer all of the questions as best you can.

SECTION A: Student information. Parents/guardians can help complete this section.

Today’s date: ______(yyyy/mm/dd)

Full name: ______OFFICE USE ONLY: How old are you: ______years old

Do you Identify as a: Subject ID: ______Boy Girl Other ______Do not want to answer

What grade are you in? ______School ID: ______Name of school: [School name – pre-filled by research team]

1. Please select the highest level of education your parent(s) have completed (circle one letter): a. Less than high school b. High school c. University degree d. College diploma, trade school, or apprenticeship e. Other: ______f. Don’t know

2. Have you ever skied before? a. Yes (if yes, for how many years: years, and how many times a year usually: ____times) b. No

3. Have you ever snowboarded before? a. Yes (if yes, for how many years: years, and how many times a year usually: ____times) b. No

4. If you have gone skiing or snowboarding before, what protective equipment do you wear? (circle all that you wear) a. Helmet b. Wrist guards c. Other (please specify):______d. None

5. How would you describe your ability level in skiing or snowboarding? (circle the answer for the sport you do most)

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a. Beginner b. Intermediate c. Advanced d. Don’t know SECTION B: Knowledge of safety and injury risk. This section is to be completed by the CHILD ONLY.

Instructions: Please answer all of the questions as best you can.

1. The best way to get ready for a day on the ski hill is to sleep well the night before, have a healthy breakfast, wearing the right clothes for the weather. a. True b. False

2. While skiing or snowboarding down a hill, you should: (circle one letter) a. Stay in control by going fast and skiing next to your buddy b. Ski or snowboard in an area away from your group c. Always check around you for other skiers and snowboarders nearby d. Ignore signs for closed off areas

3. A lot of people on the hill are going slowly and you want to get past them. What is the safest way to get around them? (circle one letter) a. Ski or snowboard closely behind them to encourage them to go faster b. Go faster and quickly pass them so you do not get stuck behind them c. Slow down, look around and pass when it is clear d. Stop on the hill, wait until it is clear and then speed past them

4. You are getting ready to get on the chair lift and it is going very fast and you are nervous. What should you do? (circle one letter) a. Tell other people that you want to take the chair lift alone b. Take off your skis/snowboard and walk on c. Ask the lift attendant or instructor to help d. Ask your parent or chaperone to drive you to the top of the hill

5. You are on a hill run and are very tired. Where is the best place to stop and rest? (circle one letter) a. In the middle of the run b. In the trees c. At the side on a flat slope d. At the side below a drop

6. You are on a steep slope that makes it hard for you to go down. What is the best way to safely reach the bottom? (circle one letter) a. Ski or snowboard down the hill slowly by making a bigger snowplow or side slipping b. Keep going as you normally would until you reach the bottom c. Take off your skis or snowboard and walk down d. Ski or snowboard as fast as possible down the hill so you don’t have to be on the steep slope

7. Someone accidentally skis or snowboards into you from behind and you both fall. You are okay, but the other person is not moving. How can you help that person? (circle one letter) a. Go and get a ski patroller to help

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b. Move the other person to a safe place c. Take off your gear d. Stay with the person and ask someone else nearby to get help from a ski patroller

8. If you were going on an EASY run the sign would be: a) Black Diamond b) Blue Circle c) Green Square 9. If you were going on an INTERMEDIATE run the sign would be: a) Black Diamond b) Blue Circle c) Green Square

10. If you were going on a HARD CHALLENGING run the sign would be: a) Black Diamond b) Blue Circle c) Green Square

11. What rule should you use when you put on your helmet: a) Shake test b) Buddy checks your helmet rule c) 2V1 Rule d) T3 Rule

12. True or false: When you wear a helmet while skiing or snowboarding, it does not matter if it is a hockey or bicycle or ski/snowboard helmet. (circle one letter) a. True b. False

13. True or false: You should be able to fit a thick and woolly hat or toque underneath your helmet for warmth. (circle one letter) a. True b. False

14. True or false: One of the main points on the Alpine Responsibility Code is to always stay in control. (circle one letter) a. True b. False

15. True or false: When you are skiing or snowboarding down the hill, you have to watch out for the people below you. (circle one letter) a. True b. False

Ski and Snowboard Survey Post-test

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This survey usually takes about 10 minutes to complete. Sections B and C are to be completed by the student only. Please answer all of the questions as best you can.

SECTION A: Student information. Parents/guardians can help complete this section. OFFICE USE ONLY: Today’s date: ______(yyyy/mm/dd)

Full name: ______Subject ID: ______How old are you: ______years old

Do you Identify as a: School ID: ______Boy Girl Other ______Do not want to answer

What grade are you in?: ______

Name of school: [School name – pre-filled by research team]

SECTION B: Knowledge of safety and injury risk. This section is to be completed by the CHILD ONLY.

Instructions: Please answer all of the questions as best you can.

16. The best way to get ready for a day on the ski hill is to sleep well the night before, have a healthy breakfast, wearing the right clothes for the weather. a) True b) False

17. While skiing or snowboarding down a hill, you should: (circle one letter) a) Stay in control by going fast and skiing next to your buddy b) Ski or snowboard in an area away from your group c) Always check around you for other skiers and snowboarders nearby d) Ignore signs for closed off areas

18. A lot of people on the hill are going slowly and you want to get past them. What is the safest way to get around them? (circle one letter) a) Ski or snowboard closely behind them to encourage them to go faster b) Go faster and quickly pass them so you do not get stuck behind them c) Slow down, look around and pass when it is clear d) Stop on the hill, wait until it is clear and then speed past them

19. You are getting ready to get on the chair lift and it is going very fast and you are nervous. What should you do? (circle one letter) a) Tell other people that you want to take the chair lift alone b) Take off your skis/snowboard and walk on c) Ask the lift attendant or instructor to help d) Ask your parent or chaperone to drive you to the top of the hill

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20. You are on a hill run and are very tired. Where is the best place to stop and rest? (circle one letter) a) In the middle of the run b) In the trees c) At the side on a flat slope d) At the side below a drop

21. You are on a steep slope that makes it hard for you to go down. What is the best way to safely reach the bottom? (circle one letter) a) Ski or snowboard down the hill slowly by making a bigger snowplow or side slipping b) Keep going as you normally would until you reach the bottom c) Take off your skis or snowboard and walk down d) Ski or snowboard as fast as possible down the hill so you don’t have to be on the steep slope

22. Someone accidentally skis or snowboards into you from behind and you both fall. You are okay, but the other person is not moving. How can you help that person? (circle one letter) a) Go and get a ski patroller to help b) Move the other person to a safe place c) Take off your gear d) Stay with the person and ask someone else nearby to get help from a ski patroller

23. If you were going on an EASY run the sign would be: a) Black Diamond b) Blue Circle c) Green Square

24. If you were going on an INTERMEDIATE run the sign would be: a) Black Diamond b) Blue Circle c) Green Square

25. If you were going on a HARD CHALLENGING run the sign would be: a) Black Diamond b) Blue Circle c) Green Square

26. What rule should you use when you put on your helmet: a) Shake test b) Buddy checks your helmet rule c) 2V1 Rule d) T3 Rule

27. True or false: When you wear a helmet while skiing or snowboarding, it does not matter if it is a hockey or bicycle or ski/snowboard helmet. (circle one letter) a) True b) False

177

28. True or false: You should be able to fit a thick and woolly hat or toque underneath your helmet for warmth. (circle one letter) a) True b) False

29. True or false: One of the main points on the Alpine Responsibility Code is to always stay in control. (circle one letter) a) True b) False

30. True or false: When you are skiing or snowboarding down the hill, you have to watch out for the people below you. (circle one letter) a) True b) False

SECTION C: Beliefs about injury risk and prevention. This section is to be completed by the CHILD ONLY after watching the video.

1. In your opinion, do you think that there is a chance of getting hurt while skiing or snowboarding on a class trip? (circle one answer)

1 2 3 4 5 6 7 Low High Extremely Quite Slightly Neither Slightly Quite Extremely

2. Do you think that you are more or less likely to get hurt than your classmates while skiing and snowboarding? (circle one answer)

Less 1 2 3 4 5 6 7 More Likely Definitely Probably Slightly Neither Slightly Probably Definitely Likely

3. Do you think that wearing a helmet that fits will help you stay safer when skiing or snowboarding? (circle one answer)

1 2 3 4 5 6 7 Disagree Agree Strongly Mostly Slightly Neither Slightly Mostly Strongly

4. Do you think that following the rules of the hill will help you stay safer when skiing or snowboarding? (circle one answer)

1 2 3 4 5 6 7 Disagree Agree Strongly Mostly Slightly Neither Slightly Mostly Strongly

5. Do you think you will be able to follow the rules of the hill when skiing or snowboarding? (circle one answer)

1 2 3 4 5 6 7 Disagree Agree Strongly Mostly Slightly Neither Slightly Mostly Strongly

178

6. How sure are you that you are able to check that your helmet fits properly? (circle one answer)

1 2 3 4 5 6 7 Unsure Sure Extremely Quite Slightly Neither Slightly Quite Extremely

7. If you get part way down a run and realize that it is too difficult for you, how sure are you that you will know what to do? (circle one answer)

1 2 3 4 5 6 7 Unsure Sure Extremely Quite Slightly Neither Slightly Quite Extremely

8. I plan to follow the rules of the hill when I go skiing or snowboarding. (circle one answer)

1 2 3 4 5 6 7 No Yes Definitely Mostly Slightly Neither Slightly Mostly Definitely

9. I plan to wear safety equipment such as a helmet every time I go skiing or snowboarding. (circle one answer)

1 2 3 4 5 6 7 No Yes Definitely Mostly Slightly Neither Slightly Mostly Definitely

10. What things would make it easier for you to stay safe on the hill? (write down as many as you can think of)

______

11. What things would make it harder for you to stay safe on the hill? (write down as many as you can think of)

______

179

Appendix P: Risky Behaviour and Actions Assessment Tool

Ski Area Data Collection Form – School Programs

Observation ID: #______AM or PM (circle) FOR SCHOOL PROGRAM PARTICIPANTS ONLY

OBSERVATION INFORMATION (ENVIRON.)(to be filled out by each observer for each data collection period) Observer: ______Date (dd-mmm-yy): ______Time period: 1. Morning 2. Afternoon Chairlift/carpet name: ______

Weather: 1. Clear 2. Overcast 3. Snowing 4. Raining 5. Fog

Light: 1. Sharp 2. Flat 3. Whiteout 4. Lights 5. Dark

Temperature: ______°C

New Snow: 1. No new 2. 0-5 cm 3.5-10 cm 4.10-15 cm 5. Over 15 cm

Surface (select all): 1. Groomed 2. Moguls 3. Powder 4. Granular 5. Hard

180

OBSERVATION INFORMATION (INDIVIDUAL ON HILL): ID #:______Activity: 1. Ski 2. Snowboard

Sex: 1. Female 2. Male 3. Don’t know

Wearing goggles: 1. Yes, over helmet 2. Yes, under helmet 3. Yes, no helmet 4. No 5. Don’t know

Wearing helmet: 1. Yes 2. No 3. Don’t know

Skiing/Snowboarding helmet?: 1. Yes 2. No If no, type (e.g. bicycle): ______3. Don’t know

Wearing wrist guards: 1. Yes 2. No 3. Don’t know

Behaviours and actions on hill (check all that apply): Visibility and Obstruction ☐ Obstructing the run with other visitors present for a significant amount of time ☐ Stopping in an area on the hill that is unsafe ☐ Stopping in an area on the hill where there is minimal to no visibility from uphill Hill Etiquette ☐ Cutting off (or cutting in front of) other visitors ☐ Skiing too close to other visitors ☐ Not yielding or giving right of way to other visitors below Collision Risk ☐ Actual collision with an object or person ☐ Visibly unable to stop or stay in control Risk-Taking Actions ☐ Excessive speed ☐ Jumping unsafely ☐ Skiing backwards Other ☐ Visibly unable to stop or stay in control ☐ Runaway equipment ☐ Skiing through closed off areas or trails ☐ Other:

Listening to music (presence of ear buds or cord): 1. Yes 2. No 3. Don’t know

Using other electronic device while skiing or Type of device (check all that apply): snowboarding: ☐ Phone 1. Yes 2. No 3. Don’t know ☐ Helmet cam (e.g. GoPro) ☐ Other (describe): ______

DID YOU SEE ANY RISKY BEHAVIOUR: YES NO

181

Appendix Q: Examples Of Video Clips

Figure Q-1. Example of Video Clip

182

Appendix R: Map for Locating Observing Sites At The Ski Area

Figure R-1. Trail map of Southern Ski Area

183

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Figure R-2. Observation Sites at Southern Alberta Ski Area

184

Appendix S: Sample Size Calculations

S.1. Sample size:

There were 96 schools that participated in ski and snowboard school programs during the 2013-

2014-winter season, representing approximately 11,513 students and 16,305 student visits. The average school cluster size was 116 students per school attending the ski and snowboard school programs. However, it is important to consider that not all schools will consent to be a part of the study. Based on this, we have to consider the feasibility of our project with the number of schools and students that will be willing to participate in each arm and the sample size required.

S.2. Knowledge:

Based on Calgary ski and snowboard school program data from 2013-2014, we can state there are potentially 96 schools and 11,513 students available to be a part of our study. However, realistically we will not have100% consent rates from schools and we will not have 100% participation rates for students within the subset of schools that consent to be a part of our study. We will assume a minimal mean change score (number of correct questions) among students in the control group (0.00) and a more substantial mean change score in the intervention group (5.00) and the standard deviation of the change in score to be 2.970343 based on a study done on general injury prevention knowledge at junior high schools in Calgary (Personal

Communication: Rebecca Carnduff, MSc Candidate, Sport Injury Prevention Centre, Faculty of

Kinesiology, University of Calgary, January 20 2016).. We can assume at minimum, we would get at least 20-30 schools and at least one classroom per school, which consists of approximately

30 students. Hayes and Bennett suggest the coefficient of variation for most health outcomes

185 would not exceed 0.5(Hayes & Bennett, 1999). Under these assumptions, that is: alpha significance level of 0.05, power of 80%, difference between groups (of change variable) of 5 points, standard deviation of 2.97 and a coefficient of variation of 0.5, we will need approximately 3 schools per group, so approximately 90 students per arm and 180 students total. Under the same assumptions, except with a larger coefficient of variation of 1.5, we would need 19 schools in each arm of the study (38 total), a sample size we are quite likely to achieve.

Data from a project examining general injury prevention knowledge at junior high schools in Calgary found a large coefficient of variation of 3.2 (Personal Communication:

Rebecca Carnduff, MSc Candidate, Sport Injury Prevention Centre, Faculty of Kinesiology,

University of Calgary, January 20 2016). With this coefficient of variation, we would need 82 schools per arm, which is not feasible. However, this coefficient of variation likely represents the extreme end of possible values and was related to the uptake of less specific injury prevention information than our focused ski and snowboard injury prevention video would provide. Even if this is we find we have a coefficient of variation of 3.2, our study will add valuable information to the literature about the potential effect of our video intervention, the logistics of carrying out such a study in elementary and junior high school students and, in that sense, provide a basis for related work in the future.

Sample Calculations:

Knowledge Uptake:

Where:

α = 0.05 = Acceptable type I error (using two-tailed test)

β = 0.20 = Acceptable type II error

186

Power = 1 – β = 80%

μiandμc are the population means in the presence and absence of the intervention (respectively).

In the context of the study, they represent the mean of the change score in knowledge (number of correct responses) before and after the intervention or control video is shown is shown. For this calculation, we will assume a substantial mean change score in the presence of the intervention,

therefore μi = 5.00. In the absence of the intervention, we will assume a minimal change score whereμc = 0.00. σi and σc are the true population standard deviations in the presence and absence of the intervention (respectively) (Personal Communication: Rebecca Carnduff, MSc Candidate,

University of Calgary, January 20 2016). n = average cluster size based on ski and snowboard school program data from 2013/2014.

11210 student/96 schools=116 students per school cluster.

The following sample size formula for clusters will be used (Hayes & Bennett, 1999):

k = 3.1577[coefficient of variation was calculated from a study related to knowledge change as a result of a neuromuscular training program (Personal Communication: Rebecca Carnduff, MSc

Candidate, University of Calgary, January 20 2016)]

! 4.307025 + 2.970343 ! ! ! (1.96 + 0.84) 116 + 3.1577 0.01 + 5.00 � = 1 + (0.01 − 5.00)!

187

7.277368 7.84 116 + 9.974 0.00001 + 25.00 � = 1 + (−4.99)!

7.84 0.0627359 + 9.974 25.0001 � = 1 + 24.9001

7.84 249.414 � = 1 + 24.9001

1955.403669 � = 1 + 24.9001

� = 1 + 78.5

� = 79.5 ≅ 80

Eighty clusters times 116 students per cluster equals a total sample size of 9,280 students per arm. The total sample size would then be 18, 560 students required overall. This number is not feasible as there were approximately 11, 210 students in the ski and snowboarding school programs during the 2013-2014 winter season. In addition to this, not all these schools and students are going to agree to participate in this project. A possible explanation for this inflated sample size is that the coefficient of variance was calculated from data from a study related to knowledge change due to a neuromuscular training program. This study is quite different from ours and therefore, the coefficient of variance is higher than expected in our study. In order to account for this, we should consider the value for the coefficient of variance used in their proposal, which was 0.06.

Considering this value placed into the following equation:

188

α = 0.05 = Acceptable type I error (using two-tailed test)

β = 0.20 = Acceptable type II error

Power = 1 – β = 80%

μiandμc are the population means in the presence and absence of the intervention (respectively).

In the context of the study, they represent the mean change in knowledge scores (number of correct responses) before and after the intervention or control video is shown is shown. For this calculation, we will assume a substantial mean change score in the presence of the intervention,

therefore μi = 5.00. In the absence of the intervention, we will assume a minimal change score

where μc = 0.00. σi and σc are the true population standard deviations in the presence and absence of the intervention (respectively) (Personal Communication: Rebecca Carnduff, MSc Candidate,

University of Calgary, January 20 2016). n = average cluster size based on ski and snowboard school program data from 2013/2014. 11210 student/96 schools=116 students per school cluster

The following sample size formula for clusters will be used (Hayes & Bennett, 1999):

k = 0.06 [coefficient of variation was used in the proposal for the neuromuscular training program study (Personal Communication: Rebecca Carnduff, MSc Candidate, University of

Calgary, August 8th, 2016)]

189

! 4.307025 + 2.970343 ! ! ! (1.96 + 0.84) 116 + 0.06 0.00 + 5.00 � = 1 + (0.00 − 5.00)!

7.277368 7.84 116 + 0.0036 0.00 + 25.00 � = 1 + (−5)!

7.84 0.0627359 + 0.0036 25.00 � = 1 + 25

7.84 0.1527 � = 1 + 25 1.1974 � = 1 + 25

� = 1 + 0.047

� = 1.047 ≅ 1

Two cluster times 116 students per cluster equals a total sample size of232 students per arm. The total sample size would then be 464 student required overall.

This sample size seems to be too small to attain a significant change. Our sample size will between 18560 and 232 students. The problem with both sample size calculations seems to be the inadequate value of the coefficient of variance, which is not realistic for this project; therefore, we will calculate a coefficient of variance for our study based on a number of assumptions:

190

Firstly, we have to assume that if we approach 100 schools, we may only have a 40% success rate. That would result in only having approximately 40 schools in our study, which means 20 schools per arm of the study. Our new cluster value would 20.

In addition to this, we cannot assume that all the students in every cluster will agree to be apart of the knowledge uptake portion of this study. From the 2013-2014 ski season, the average cluster size (n) was calculated to be 116 students per school cluster (11210 student/96 schools=116 students). Assuming 70% of students in each cluster participate in the study, the new average cluster size (n) will be 81 students per cluster.

Still following the α = 0.05 = Acceptable type I error (using two-tailed test), β = 0.20 =

Acceptable type II error, and Power = 1 – β = 80%. μiandμc are still the population means in the presence and absence of the intervention (respectively). In the context of the study, we will

assume a substantial mean change score in the presence of the intervention, therefore μi = 5.00.

In the absence of the intervention, we will assume a minimal change score where μc = 0.00. σi and σc are the true population standard deviations s in the presence and absence of the intervention (respectively) (Personal Communication: Rebecca Carnduff, MSc Candidate,

University of Calgary, January 20 2016).

Using all these assumptions the new coefficient of variance will be calculated below:

191

(20 − 1)(0 − 5)! 4.307025! + 2.970343! − (1.96 + 0.84)! 81 � = 0! + 5!

(19)(25) 4.307025! + 2.970343! − (7.84) 81 � = 25

60.5 − 0.3379 � = 25

60.24 � = 25

� = 2.40995

� = 1.55234

192

The new coefficient of variance calculated is 1.55234

In addition, we also find that Hayes and Bennett suggest that “K is often <=0.25, and seldom exceeds 0.5 for most health outcomes. Therefore, using these two separate K values we can calculate a sample size based on this as well.

Using the new coefficient of variance we can calculate a new sample size. In order to show all the different sample sizes calculated before, see table S.1 below:

193

Table S.1. Variations in sample size dependent on the variables

K # of Sample Total

standard standard (coefficient population population average clusters size per sample

Z- Z- error deviation of mean mean cluster needed arm size alpha/2 beta (control) (intervention) variation) (control) (intervention) size required

1.96 0.84 4.307025 2.970343 3.1577 0 5 116 80 9280 18560

1.96 0.84 4.307025 2.970343 3.1577 0 2 116 81 9396 18592

1.96 0.84 4.307025 2.970343 3.1577 0 5 81 80 6480 12960

1.96 0.84 4.307025 2.970343 3.1577 0 2 81 81 6561 13122

1.96 0.84 4.307025 2.970343 3.1577 0 5 30 80 2400 4800

1.96 0.84 4.307025 2.970343 3.1577 0 2 30 81 2430 4860

1.96 0.84 4.307025 2.970343 0.06 0 5 116 1 116 232

1.96 0.84 4.307025 2.970343 0.06 0 2 116 2 232 464

1.96 0.84 4.307025 2.970343 0.06 0 5 81 1 81 162

1.96 0.84 4.307025 2.970343 0.06 0 2 81 2 162 324

1.96 0.84 4.307025 2.970343 0.06 0 5 30 1 30 60

1.96 0.84 4.307025 2.970343 0.06 0 2 30 2 60 120

1.96 0.84 4.307025 2.970343 0.5 0 5 116 3 348 696

1.96 0.84 4.307025 2.970343 0.5 0 2 116 4 464 928

1.96 0.84 4.307025 2.970343 0.5 0 5 81 3 243 486

1.96 0.84 4.307025 2.970343 0.5 0 2 81 4 324 648

1.96 0.84 4.307025 2.970343 0.5 0 5 30 3 90 180

1.96 0.84 4.307025 2.970343 0.5 0 2 30 4 120 240

1.96 0.84 4.307025 2.970343 1.55234 0 5 116 20 2320 4640

1.96 0.84 4.307025 2.970343 1.55234 0 2 116 21 2436 4872

1.96 0.84 4.307025 2.970343 1.55234 0 5 81 20 1620 3240

1.96 0.84 4.307025 2.970343 1.55234 0 4 81 20 1620 3240

1.96 0.84 4.307025 2.970343 1.55234 0 3 81 21 1701 3402

1.96 0.84 4.307025 2.970343 1.55234 0 2 81 21 1701 3402

1.96 0.84 4.307025 2.970343 1.55234 0 5 30 20 600 1200

1.96 0.84 4.307025 2.970343 1.55234 0 4 30 20 600 1200

1.96 0.84 4.307025 2.970343 1.55234 0 3 30 21 630 1260

1.96 0.84 4.307025 2.970343 1.55234 0 2 30 21 630 1260

194

S.3. Risky Behaviour:

There is no information available on the reported rates of unsafe or risky behaviours among children and adolescents on ski hills, which limits our ability to determine sample size for the behavioural component of the study. We base our sample size estimate on the following assumptions:

- The observers will be out on the ski hill for approximately 2 hours - The time taken to complete the behavioural form will be approximately 5 minutes (including the time it takes the child to ski down the hill) - We will be observing on at least 15 separate days. Approximately, 8 days for intervention groups and 8 days for control groups. Taking all of these considerations into account, we will approximate 360 behavioural forms per research assistant, for the project overall. We will have information on 360 runs and this information will be used to calculate the rate of number of dangerous actions performed per 100 runs. In addition, we will use 95% Confidence intervals to look at our accuracy within the sample size.

S.3.1 Sample Calculation from proposal:

There is no information available that we know of on the reported rates of unsafe or risky behaviours among children and adolescents on ski hills, which limits our ability to determine sample size for the behavioural component of the study. For this sample size calculation, we cautiously assumed a minimal unsafe behaviour rate of 10 behaviours per 100 student-hours as a baseline rate for the control group and approximated that the video intervention will reduce unsafe behaviours by 50% (RR=0.5). Similar to the knowledge uptake outcome, we would estimate the average school cluster size to be 116 students per school based on Calgary ski and

195 snowboard school program data from 2013/2014. Again using the sample size formula for cluster randomized trials by Hayes and Bennett, we estimate that we would need approximately

21 clusters per arm to have over 80% power to detect a rate ratio of 0.5. Therefore, we will require 42 observation days to meet the required sample size of 2,436 students in each arm (total of 4,872).

Risky Behaviour:

Where:

α = 0.05 = Acceptable type I error (using two-tailed test)

β = 0.20 = Acceptable type II error

Power = 1 – β = 80%

pi and pc are the expected population proportions in the presence and absence of the intervention

(respectively). In the context of the study, they represent the proportion of school program students expected to perform a risky behaviour on the ski hill after watching the intervention or control video. If we cautiously assume a minimal rate in which unsafe behaviours are performed in a ski area per student-

hour (a minimum of 10% of students), then in the absence of the intervention pc = 0.10. If we aim to reduce the amount of unsafe behaviours performed by half (RR=0.5), then in the presence of the

intervention, pi = 0.05. n = average cluster size based on ski and snowboard school program data from 2013/2014. 11210 student/96 schools=116 students per school cluster

The following sample size formula for clusters will be used (Hayes & Bennett, 1999):

196

! �! 1 − �! �! 1 − �! ! ! ! (�!/! + �!) � + � + � �! + �! � = 1 + ! (�! − �!)

k = 0.639 (coefficient of variation was calculated from 2013/2014 school program data)

! 0.10 1 − 0.10 0.05 1 − 0.05 ! ! ! (1.96 + 0.84) 116 + 116 + 0.639 0.10 + 0.05 � = 1 + (0.10 − 0.05)!

0.09 0.0475 ! ! ! 7.84 116 + 116 + 0.639 0.10 + 0.05 � = 1 + (0.05)!

7.84 0.00077586 + 0.0004095 + 0.408321 0.01 + 0.0025 � = 1 + 0.0025

7.84 0.0062893575 � = 1 + 0.0025

0.0493 � = 1 + 0.0025

� = 1 + 19.72

� = 20.72 ≅ 21

Twenty-one clusters times 116 students per cluster equals a total sample size of 2436 students per arm.

Therefore, 42 observation days (average cluster size of 116 students) will be required to meet the sample size for each arm.

197

Injury Risk:

Where:

α = 0.05 = Acceptable type I error (using two-tailed test)

β = 0.20 = Acceptable type II error

Power = 1 – β = 80%

pi and pc are the true population proportions in the presence and absence of the intervention (respectively).

In the context of the study, they represent the proportion of students expected to obtain a ski-related injury after watching the intervention or control video. Based on ski and snowboard school program data

from 2013/2014, in the presence of the intervention, pi = 0.0033, and in the absence of the intervention, pc

= 0.0066 (RR=0.5). n = average cluster size based on ski and snowboard school program data from 2013/2014. 11210 student/96 schools=116 students per school cluster

The following sample size formula for clusters will be used (Hayes & Bennett, 1999):

! �! 1 − �! �! 1 − �! ! ! ! (�!/! + �!) � + � + � �! + �! � = 1 + ! (�! − �!)

k = 0.639 (coefficient of variation was calculated from 2013/2014 school program data)

198

�

= 1

! 0.0066 1 − 0.0066 0.0033 1 − 0.0033 ! ! ! (1.96 + 0.84) 116 + 116 + 0.639 0.0066 + 0.0033 + (0.0066 − 0.0033)!

0.00655644 0.00328911 ! ! ! 7.84 116 + 116 + 0.639 0.0066 + 0.0033 � = 1 + (0.0033)!

7.84 0.00005652 + 0.00002835 + 0.408321 0.00004356 + 0.00001089 � = 1 + 0.00001089

7.84 0.000107103 � = 1 + 0.00001089 0.0008397 � = 1 + 0.00001089

� = 1 + 77.106

� = 78.106 ≅ 79

Seventy-nine clusters times 116 students per cluster equals a total sample size of 9164 students per arm.

199

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