Protective eyewear promotion: applying principles of behaviour change in the design of a squash injury prevention programme

Eye injuries in squash have the potential to be severe. Although these injuries can be prevented through the use of protective eyewear, few players wear such eyewear. The aim of this paper is to outline the behavioural principles guiding the design of a squash eyewear promotion initiative, the Protective Eyewear Promotion (PEP). Ecological principles of behaviour change were used to provide a comprehensive perspective on intrapersonal factors, policies and physical environmental influences of protective eyewear use. Results of baseline player surveys and venue manager interviews were used to provide relevant and specific intervention content. At baseline, protective eyewear was not found to be readily available, and players' behaviours, knowledge and attitudes did not favour its use. The main components of PEP involved informing and educating both players and squash venue operators of the risk of eye injury and of appropriate protective eyewear, as well as assisting with the availability of the eyewear and offering incentives for players to use it. A structural strength of PEP was the strong collaborative links with the researchers of different disciplines, the squash governing body, eyewear manufacturers, squash venue personnel, as well as players. Attempts were made within the project structure to make provision for the future dissemination and sustainability of more widespread eye injury prevention measures in the sport of squash.     

The effectiveness of a squash eyewear promotion strategy

Objective: To evaluate the protective eyewear promotion (PEP) project, which was a comprehensive educational strategy to increase the use of appropriate protective eyewear by squash players. Methods: An ecological study design was used. Four squash venues in one playing association were randomly chosen to receive PEP and four in another association maintained usual practice and hence formed a control group. The primary evaluation measurements were surveys of cross sectional samples of players carried out before and after the intervention. The surveys investigated players'' knowledge, behaviours, and attitudes associated with the use of protective eyewear. The survey carried out after the intervention also determined players'' exposure to PEP. Univariate and multivariate analyses were undertaken to describe differences at PEP venues from pre- to post-intervention and to compare these with the control venues. Results: The PEP players had 2.4 times the odds (95% confidence interval, 1.3 to 4.2) of wearing appropriate eyewear compared with control group players post-intervention, relative to the groups'' pre-intervention baselines. Components of PEP, such as stickers and posters and the availability and prominent positioning of the project eyewear, were found to contribute to players adopting favourable eyewear behaviours. Conclusions: Components of the PEP intervention were shown to be effective. The true success will be the sustainability and dissemination of the project, favourable eyewear behaviours, and evidence of the prevention of eye injuries long into the future.     

Have the attitudes of Australian squash players towards protective eyewear changed over the past decade?

OBJECTIVE: To assess indicative trends in the use of protective eyewear by Australian squash players and their attitudes towards its use since 1989. METHODS: Data were extracted from three Australian surveys of squash players conducted in 1989, 1995, and 2000. Responses to directly similar attitudinal questions relating to protective eyewear use from each survey were compared. The proportion of players giving each response was calculated for each survey, along with 95% confidence intervals for the differences between the 2000 survey and those from the earlier surveys. RESULTS: Self reported use of protective eyewear ranged from 10.0% in 1989, to 8.6% in 1995, and 18.8% in 2000. However, only 8.9% of the players surveyed in 2000 actually wore appropriate standards approved/polycarbonate lens eyewear. This can be compared with 8.0% and 2.0% of players who reported wearing appropriate polycarbonate lens eyewear in the 1989 and 1995 surveys respectively. Compared with the 1995 survey, significantly more players in 2000 believed that more players should wear protective eyewear (95% confidence interval (CI) for difference 1 to 18). A significantly higher proportion of players also supported the compulsory use of protective eyewear by juniors in 2000 than in both 1989 (95% CI for difference 6 to 24) and 1995 (95% CI for difference 5 to 22). No other attitudes had significantly changed over the decade. CONCLUSION: These data suggest that self reported use of protective eyewear has probably increased over the past decade. However, many players report wearing inappropriate eyewear. A transition from positive attitudes to appropriate eyewear behaviours is required before mandatory protective eyewear use can be effectively introduced.     

Do squash players accurately report use of appropriate protective eyewear?

Self-report surveys are a common method of collecting data on protective equipment use in sport. The aim of this study was to assess the validity of self-reported use of appropriate protective eyewear by squash players. Surveys of squash players' appropriate protective eyewear behaviours were conducted over two consecutive years (2002 and 2003) at randomly-selected squash venues in Melbourne, Australia. Over the two years, 1219 adult players were surveyed (response rate of 92%). Trained observers also recorded the actual on-court appropriate protective eyewear behaviours of all players during the survey sessions. Eyewear use rates calculated from both data sources were compared. The self-reported appropriate protective eyewear use rate (9.4%; 95% CI 7.8, 11.0) was significantly higher (1.6 times more) than the observed rate (5.9%; 95%CI 4.6, 7.2). This suggests that players may over-report their use of appropriate protective equipment, though some may have incorrectly classified their eyewear as being appropriate or suitably protective. Studies that rely only on self-report data on protective equipment use need to take into account that this could lead to biased estimates.     

Community football players' attitudes towards protective equipment--a pre-season measure

Background: The Australian football injury prevention project (AFIPP) was a randomised controlled trial examining the effects of protective equipment on injury rates in Australian Football.

Objective: To present the results of the AFIPP baseline survey of community football players' attitudes towards protective equipment.

Methods: Teams of players were recruited from the largest community football league in Victoria, Australia, during the 2001 playing season; 301 players were enrolled in the study and all were surveyed before the season began about their attitudes towards protective headgear and mouthguards.

Results: Almost three quarters of the players (73.6%) reported wearing mouthguards during the previous playing season (year 2000) compared with only 2.1% wearing headgear. The most common reasons for not wearing headgear and mouthguards (in non-users) were: "I don't like wearing it" (headgear: 44.8%; mouthguards: 30.6%), and "It is too uncomfortable" (headgear: 40.7%; mouthguards: 45.8%).

Conclusions: The higher mouthguard usage reflects the favourable attitudes towards mouthguards by Australian football players generally. Similarly, the low headgear usage reflects the low acceptance of this form of protection in this sport. Further research should be directed towards establishing the reasons why players seem to believe that headgear plays a role in injury prevention yet few wear it.

     

Floorball‐related eye injuries: The impact of protective eyewear

Several previous studies have shown that floorball belongs to a high‐risk group of sports in terms of eye injuries. Protective eyewear is available, but the extent of its use and impact on eye injuries are unknown. The purpose of this study was to investigate the current incidence of eye injuries caused by floorball and to compare it with the present use of protective eyewear. Medical records were used to identify all eye injuries suffered while playing floorball in Jönköping County from 2008 to 2011 (N = 167). All these patients were sent a questionnaire that included inquiries about the use of protective eyewear. The study shows that floorball caused more eye injuries than all other sports combined (56%). Prolonged decreased visual acuity was very unusual (0.5%), but moderate eye injuries with some risk of future problems were seen in 62% of the sample. More than one fifth of the injured patients reported some kind of vision‐related problem 2–7 years after the original injury. Only one player had been using protective eyewear at the time of injury. Our results underline the importance of protective eyewear to prevent floorball‐related injuries.     

Head and face injuries in scholastic women's lacrosse with and without eyewear.

PURPOSE: The use of protective equipment has been absent or inconsistent in scholastic women's lacrosse leading to increasing concern for eye and head injury. There is a paucity of field data, however, on which to base strategic decisions on how best to prevent head injuries in young athletes. METHODS: This study examined the effects of protective eyewear on injury rates in scholastic women's lacrosse in a cohort of approximately 700 varsity and junior varsity players in central New York studied prospectively for 2 yr during a transition from sparse to almost complete eyewear use. RESULTS: The overall head/face injury rate was 0.71 injuries per 1000 exposures (games and practices) and was 16.5% lower in goggle wearers. In games alone, where more aggressive play and stick use prevails, the rate associated with protective eyewear use was markedly lower (51%). Considering specific regions, the rates for peri-orbit and forehead injuries among goggle users were substantially lower than for nonusers (6% and 13%, respectively). Cheek and scalp injury rates tended to be higher among goggle wearers, but not statistically significantly so. Significant compensatory increases with goggle wear at other sites were not observed. Only a few injuries appeared to be mediated by the goggles themselves and potentially could have been more serious if the goggles had not been present. No direct eye (orbit) injuries were reported throughout the study period. CONCLUSION: On balance, then, the use of eyewear in women's lacrosse appears to be beneficial when users are compared with nonusers.     

Protective equipment use among female rugby players.

OBJECTIVES: Our objective was to assess the prevalence of protective equipment use and the motivation for using protective equipment among a sample of US female rugby players. DESIGN/METHODS: We surveyed a convenience sample of 234 current US female rugby players from 14 teams participating in a US women's rugby tournament, obtaining self-reported demographic, rugby exposure, and protective equipment use information. RESULTS: Mouthguards were the most commonly used piece of protective equipment: 90.8% of players reported having always worn a mouthguard while playing or practicing rugby within their most recent 3 months of play. Fewer than 15% of players reported having always worn other types of protective equipment. Equipment use varied by playing position. Whereas over 80% of players in all other positions always wore a mouthguard, 66.7% of scrum halves reported always wearing one. Both backs and forwards reported wearing shoulder pads, but only forwards reported always wearing padded headgear. Mouthguards, padded headgear, and shoulder pads were worn "to prevent injury," whereas ankle braces, neoprene sleeves, and athletic tape on joints were worn "to protect a current/recent injury." CONCLUSIONS: This is the first study of female rugby players to assess the prevalence of protective equipment use by playing position and the motivation for using protective equipment. With the exception of mouthguards, US female rugby players infrequently use protective equipment. Protective equipment use varies by playing position. Some types of protective equipment appear to be used as primary prevention mechanisms, whereas others are used as secondary or tertiary prevention mechanisms.     

Student of Motion Is a Study in Motion

In brief: The author discusses 19 ocular injuries in squash and racquetball players who wore eye guards with an opening between the upper and lower rim. The more recently developed eye guards that protect the eye with thick plastic should prevent direct injury from rackets or balls.     

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

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

What do under 15 year old schoolboy rugby union players think about protective headgear?

OBJECTIVES: When protective headgear is designed, the attitudes of the intended users needs to be taken into account, as well as safety performance criteria. The aim of this study was therefore to determine the attitudes of schoolboy rugby union players towards protective headgear. METHODS: A survey of 140 rugby union players (82.4% response rate) from 10 randomly selected school teams in metropolitan Sydney was conducted at the end of the 1999 playing season. All players were aged 14-16 years. All teams had participated in a trial of headgear during the 1999 season in which six of the teams had been assigned to a headgear trial arm and four teams to a control arm. Players completed a self report questionnaire during a supervised session at school. The questionnaire collected information on recent head injuries, use of protective equipment, and attitudes towards headgear. RESULTS: Some form of protective equipment was always worn by 76.1% of players: 93.6% reported using a mouthguard and 79.3% a helmet/headgear during the 1999 season. The two most important reasons for wearing headgear were related to safety concerns. Players with no recent head/neck injury were more likely to report that they felt safer when wearing headgear (p<0.001) and less likely to cite a previous injury as a motivating factor for wearing headgear (p<0.001) than those who had sustained a recent head/neck injury. Of the players who wore headgear during the 1999 season, 67% said that they played more confidently when they wore headgear, but 63% said that their head was hotter. Few players reported that their head was uncomfortable (15%) or that it was hard to communicate (3%) when they wore headgear. The main reasons for not wearing headgear were related to its design features: uncomfortable (61%) and it was hot (57%). CONCLUSIONS: The primary reason cited by players for wearing headgear is safety. Receiving an injury would also motivate non-wearers to wear headgear. Players report that they are more confident and able to tackle harder if they wear headgear, suggesting that a belief in its protective capabilities may influence behaviour. These attitudes need to be addressed in the design of effective headgear as well as in strategies to promote its use.     

Sports-related eye injuries: floorball endangers the eyes of young players

The objectives of this study were to determine the distribution of different sports-related eye injuries and to identify injury types to enable recommendations to be made about the use of protective eyewear. The study population comprises all 565 eye trauma patients examined at the Ophthalmology Emergency Clinic of the Helsinki University Central Hospital over a 6-month period. Data were collected from patient histories and questionnaires. In addition, three severe floorball eye injury cases are presented. Of the 565 eye traumas, 94 (17%) were sports related. Of these, 42 (45%) were associated with floorball. Countrywide, in Finland, estimated over 300 (+95% CI 228-415) floorball eye injuries occur annually. The mean age of floorball patients was 22 years. The most common finding (55%) in sports injury patients was hyphema. Clinically severe eye injuries during this period accounted for one-fourth of all cases. During the study period, no eye injury was found in an organized junior ice hockey, where facial protection is mandatory. Floorball is estimated to belong to the highest risk group in sports, and thus, the use of protective eyewear is strongly recommended. We conclude that national floorball federations should make protective eyewear mandatory.     

Ocular injury in hurling

Objectives: To describe the clinical characteristics of ocular injuries sustained in hurling in the south of Ireland and to investigate reasons for non-use of protective headgear and eye wear. Results: Hurling related eye injuries occurred most commonly in young men. Fifty two patients (17%) required hospital admission, with hyphaema accounting for 71% of admissions. Ten injuries required intraocular surgical intervention: retinal detachment repair (5); macular hole surgery (1); repair of partial thickness corneal laceration (1); repair of globe perforation (1); enucleation (1); trabeculectomy for post-traumatic glaucoma (1). Fourteen eyes (4.5%) had a final best corrected visual acuity (BCVA) of <6/12 and six (2%) had BCVA <3/60. In the survey, 63 players (48.5%) reported wearing no protective facemask while playing hurling. Impairment of vision was the most common reason cited for non-use. Conclusions: Hurling related injury is a significant, and preventable, cause of ocular morbidity in young men in Ireland. The routine use of appropriate protective headgear and faceguards would result in a dramatic reduction in the incidence and severity of these injuries, and should be mandatory.     

Ocular sports injuries: the current picture

Objectives—To determine the recent incidence of eye injury due to sport in Scotland, identify any trend, and establish which sports are responsible for most injury? The type of injury and final visual outcome is also evaluated. Methods—A prospective observational study of ocular injuries sustained during sport was performed over a one year period. Only patients requiring hospital admission were included. Data were collected on a standardised proforma and entered into a central database. Patients were followed up for at least three months. Results—Of 416 patients admitted because of ocular injury, 52 (12.5%) resulted from playing a sport. Although all racquet sports together accounted for 47.5% of these injuries, football was the single most common sport associated with ocular trauma, being responsible for 32.5% of cases. The most common clinical finding was macroscopic hyphaema occurring in 87.5% of patients. Overall the final visual acuity was 6/6 in 92.5% of patients. Conclusions—The incidence of eye injury due to sport at 12.5% is lower than previously reported, suggesting a change in the pattern of ocular trauma. Football is the single most common cause of ocular injury from sport in Scotland, but the wearing of protective headgear would be difficult to instigate. The incidence of hyphaema in sport related ocular trauma (87.5%) is almost double that of all ocular injury (47.8%), so the potential for serious visual loss as the result of a sports injury should not be underrated. Ophthalmologists have a role in protecting this young population at risk by actively encouraging the design and use of protective eyewear. Key Words: eye injury; ocular trauma; hyphaema; protective eyewear     

Ocular injuries in basketball and baseball: what are the risks and how can we prevent them?

Ocular trauma is a frequent result of sports-related injury during basketball and baseball. A screening sideline examination should be performed immediately to assess vision and evaluate the severity of damage. The team physician should be able to treat minor injuries and identify vision-threatening trauma for immediate referral. Injuries range from minor, including corneal abrasion and foreign bodies, to more severe, including hyphema, orbital fracture, and globe rupture. Resultant damage may be vision-threatening and permanent. Most of these injuries can be prevented with full-time use of sport-specific protective eyewear. Physicians should recommend appropriate eye protection and counsel patients accordingly.     

Applied physiology of squash

Squash is a moderate- to high-intensity intermittent exercise. Players are active 50 to 70% of the playing time. 80% of the time, the ball is in play 10 seconds or less. The rest intervals fit a normal distribution with an average duration of 8 seconds. Heart rate increases rapidly in the first minutes of play and remains stable at approximately 160 beats/min for the whole match no matter what levels the players are. The energy expenditure for medium-skilled players is approximately 2850 kJ/h and over 3000 kJ/h for A grade players. The thermal and metabolic response to squash is similar to that of moderate intensity running. Hyperglycaemia, elevated free fatty acids and growth hormone levels, and low serum insulin values are the common metabolic changes. Blood lactate levels are understandably low due to the very short work to rest pattern of play. Injuries are not frequent in squash but they can occur. Serious eye injuries have been documented and as a result protective equipment is highly recommended. To reduce the possibility of sudden death on the court or after the game, older players that present some risk factors for cardiovascular disease should be warned against smoking after the game and informed of the serious implications of the development of chest pain, or undue tiredness before, during or after squash.     

Performance of Eye Protectors for Squash and Racquetball

Although squash and racquetball eye protectors are available and many people wear them, eye injuries still exist. The authors studied the ability of the 13 eye protectors currently available in Canada to protect the players' eyes. The eye guards were mounted on a headform, and balls were thrown at it at speeds from 50 to 100 mph. This was recorded on high-speed film that was analyzed to determine ball speed, lens or frame deformation, and damage during impact. Eye contact with protectors having lenses was confirmed only once in 54 impacts. All 17 hits to the open eye guards produced ball-eye contact. The authors suggest that standards for eye protectors should be established.     

Coach and player attitudes to injury in youth sport

ObjectivesTo investigate coach and player attitudes to injury in New Zealand (NZ) secondary school sport.DesignCross-sectional surveySettingSecondary school sport.ParticipantsSecondary school coaches and players.Main outcome measuresResponses to a survey of injury attitudes. The survey was distributed in electronic and paper-based form to secondary school coaches and players across three sporting organisations. Coaches’ uptake of injury prevention training and whether they had first aid qualifications was also elicited.Results117 coaches and 226 players from netball, football and basketball participated. The majority of coaches surveyed (n = 82, 70%) reported having a coaching qualification and 72 (62%) had completed a sport related first aid/injury prevention programme. Overall, 196 players (87%) reported hiding an injury to continue playing, and 102 coaches (87%) and 205 players (91%) had witnessed injured players play on. Approximately 50% of players and coaches had seen players put under pressure to play when injured. A lack of knowledge, the desire to win, and not letting the team down were key reasons given for the behaviour reported.ConclusionsThe observed prevalence of players playing on when injured and associated attitudes to secondary school sport injuries demands further investigation.