Victorian Sports Injury Prevention Program: An overview

David Rich Program Manager, Victorian Sports Injury Prevention Program, Sports

Medicine Australia (Victorian Branch)

In Australia, more than one million people report sporting injuries every year. Sports Injury Prevention has been identified as a public health issue in the 1994 Commonwealth Department of Human Services and Health (DHSH} report Better Health Outcomes for Australians. In addition to health costs, the economic and social cost of these injuries to individuals and the community at large are significant. The Australian Sports Commission established the Australian Injury Prevention Taskforee (AIPT) in 1995 to provide direction in counteracting sports injury. One of the recommendations of the AIPT was to develop and implement a systematic approach to injury prevention through a State and national sports safety program. This recommendation was supported by the DHSH, Sport and Recreation Victoria and the Victorian Health Promotion Foundation (VicHealth). These three bodies provided funding for a program to be developed and sit within the Victorian Branch of Sports Medicine Australia. This program, titled the Victorian Sports Injury Prevention Program (VSIPP), began in May 1998. The VSIPP has three core strategies in the initial 12 months of the program. This paper will discuss the reasons why such a strategic approach will target a lack of training in injury prevention, particularly in many rural areas.

In t roduct ion Injury prevention has been identified as a public health issue in Australia by the Commonwealth Department of Human Services and Health in their 1994 report Bet ter Health Outcomes for Australians and by the Victorian Department of Human Services (DHSH) report Taking Injury Prevention Forward (1994). "Australian Health Ministers have endorsed the concept of setting national goals and targets as a means of making significant improvements in the health status of Australians." (TIPF 1994, pl).

As a result of setting national goals and targets, the Australian Sports Injury Prevention Taskforce was established in 1995 to promote a national agenda on sports injury prevention by the federal Minister for Human Services and Health and the Minister for Environment, Sport and Territories.

Subsequent to the recommendations by the Australian Sports Injury Prevention Taskforce, the Victorian Sports Injury Prevention Program (VSIPP) was formed in June 1998. This Program, supported by a tripartite agreement between Sport and Recreation Victoria (SRV), the DHS and the Victorian Health Promotion Foundation (VicHealth), sits within the Victorian Branch of Sports Medicine Australia.

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The goal of the VSIPP is: "to reduce the prevalence and severity of in jury in sport and physical activity and promote hea l thy participation through partnerships involving peak sports bodies, agencies, government and the community" within the State of Victoria.

Strategies to achieve this goal include: • Develop a communication strategy

• Develop r e s o u r c e s for c o m m u n i t y use i n c l u d i n g a ' r i sk management ' model for sports injury prevention

• Support research in sports injury prevention

• Establish and monitor a resource exchange centre

• Develop and support partnerships with peak organisations, local government and communi ty sport and recreation groups to address injury prevention. A State-wide approach is deemed to be a cost-effective strategy

for the reduction of injury by these government and non-government agencies. However, this approach should not lose sight of a bottom- up, top-down approach to sports injury prevention.

I n j u r y P r e v e n t i o n a s a P u b l i c H e a l t h I s s u e Accidents have always been a part of the history of mankind. All living creatures, particularly humans, are prone to accidents which can result in scale from a near-miss to a fatality. Until recently, accidents were seen as the concern of the individual and not the State. The Indus t r i a l Revolution of the 1880's resu l ted in a realisation that government and the private sector needed to have some responsibility of accident prevention, particularly in light of the economic and social impact on the community.

However, it was not until the twentieth century that government regulations came into effect to reduce the worst of the industrial hazards. Since the formation of the Safety Council in 1912 in England, the proportion of accidental deaths has decreased by over 50 percent, resulting in around two and a half millions lives saved (Thygerson , 1992). These r e s u l t s were p r imar i l y due to environmental changes and improved technology on safety and legislation. It is only in the last half of this century that behavioural change has been targeted to further reduce injury, both intentional & non-intentional.

Although injury is identified as one of the top five public health issues, developing countries largely accept injury as the individual's concern. Immediate survival all too often takes precedence over preventative measures. Famine and disease are more immediate concerns, even though injury, both intentional and non-intentional are a major cause of death.

In developed countries, there is emphasis on both individual responsibility, through public health campaigns and government (or social) responsibi l i ty , t h rough regulat ion, legislat ion and

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c o m p e n s a t i o n . The Fede ra l g o v e r n m e n t (Commonwea l th Department of Health and Family Services) has identified injury as one of the four health focus areas which include cardiovascular disease, cancers and mental health (CDHSH, 1994). At the State level, the Department of Human Services has identified sport and recreation injury prevention as an immediate priority along with injuries to children and older people (TIPF, 1994).

The Cost of Injury Injury ranks fourth behind circulatory, musculo-skeletal and mental disorders in terms of direct health care costs in Australia and ranks third in terms of the number of deaths, behind circulatory disease and cancer (Mathers et al, 1997). However, the importance of injury prevention as a public health issue is highlighted where injury ranks first ahead of cancer and circulatory disease for years lost to the age of 65 (Ginpil et al, 1992).

"Injury is the leading cause of death of persons aged between 1 and 44 years, accounting for up to 72% of deaths in some age groups (e.g. 15-24 years)", (Watson, Ozanne-Smith, 1997. piii). This accoun t s for an enormous economic cost to the communi ty , determined at $11 billion per year during 1986 alone. Injury places great strain on our hospital and medical system. "In 1993, 466,200 persons sought medical treatment in Victoria at a cost of $2,582.9 million, or an average of $5,541 per injured person...more than 59,000 life-years (to age 75) are lost (46.5 days per injured person) as a result of injuries sustained in 1993/94, valued at $1,010.5 million." (Watson, Ozanne-Smith, 1997. p39).

The extent of injury as a health problem is emphasised where injury is underrepresented due to the degree of non-reporting of injuries. This is illustrated in Figure 1.

The direct cost to the Australian community of injury through sport is around $298 million. Over one third of this is attributable to Australian Rules Football (Egger, 1990). In 1993, 2,500 people were admitted to hospital for sports related injuries (VIMD, 1994). However, as with other streams of injury prevention, the majority of injuries sustained in sport are never reported to hospitals.

Contact sports are more often associated with injury. Football, soccer, basketball, cricket and netball have been implicated as sports associa ted with a high occurrence of injury, with the frequency of injury to males far exceeding those to females (Routley, 1991). It is necessary when interpreting this data, that these 5 sports implicated with high injury are identified as those having the greatest participation rates. Consequently, as with all risk m a n a g e m e n t guidel ines , g rea te r exposure to a hazard often correlates to an increase in injury rates. This correlation is evident in injury data from NSW where rugby league (36%) and rugby union (35%) demonstrated higher injury rates for all sports, shown as a percentage of participation in each sport (Northern Sydney Area

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Service, 1997). These figures were above the injury rates for football (Australian Rules), soccer and netball. There are consistent findings that sports related injuries occur to younger people, particularly those under 30 years of age (Routley & Valuri, 1993; Northern Sydney Area Service, 1997). Forty-four per cent of all injuries in these age groups are related to sport and recreational activities (ABS, 1991).

A statewide approach to reduce sports related injury has been a long-s tand ing i tem on the hea l th agenda. Al though injury prevention, particularly non-intentional injury prevention, has been identified by both state and federal governments as a public health issue, it has been the poor cousin in the financial and political health stakes. This is in part due to a reflection of public interest in non-intent ional injury prevention. The fight for the slice of adequate funding has been constrained by the "multi-disciplinary and intersectoral nature of the development and implementation of injury prevention" (Kreisfeld, R., 1998, p5).

Since injury prevention is a segregated responsibil i ty of key stakeholders, specialising in road safety, child safety, farm safety, sport safety, falls prevention, fire prevention and intentional injury prevention, there is not a unified lobby group to provide the p ressure on government for injury prevent ion to take greater precedence. This, in some way, has been addressed through the formation of the Austral ian Injury Prevention Advisory Council (NIPAC), the Australian Injury Prevention Network {AIPN), the Safe Communities Network and the Victorian Injury Control Forum (a DHS Committee). These groups provide a voice to both federal and s ta te government ministers . However, they are either in their formative stages of development, or in a process of restructure. Consequently, further lobbying is required to government before

Figure 1: The extent of injury as a health problem is emphasised where injury is underrepresented due to the degree of non-reporting of injuries (from Watson & Ozanne- Smith (1997), p. xv.

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injury receives the financial supports that is warranted in relation to other public health issues such as cardiovascular disease, cancer, cerbrovascular disease.

Sports injury prevention, as one stream of injury prevention, has been a victim of this mul t i -d isc ipl inary and intersectoral a p p r o a c h . There has been c o n s i d e r a b l e d i s c u s s i o n among government depar tments as to where sports injury prevention should sit. Stakeholders in sports injury prevention include the Commonwealth Department of Health and Family Services, the Australian Sports Commission, the Victorian Departments of Human Services, Sport and Recreat ion and Ju s t i c e along with non- government organisat ions such as VicHealth, Sports Medicine A u s t r a l i a and spor t a s s o c i a t i o n s . C o n s e q u e n t l y , all t h e s e government and non-government organisations have historically contributed to sports injury prevention without one body taking direct responsibil i ty for resourcing and directing preventative measures .

The Future for Sports Injury Prevention in Victor ia An approach to rectifying this problem has been taken collectively by Sport and Recreation Victoria, the Department of Human Service and the Victorian Health Promotion Foundation (VicHealth). A tri- pa r t i t e ag reemen t , ba sed u p o n r e c o m m e n d a t i o n s from the Austral ian Sports Injury Prevention Taskforce (ASIPT) and the Taking Injury Prevention Forward report (DHS) has resulted in the rise of the Victorian Sports Injury Prevention Program (VSIPP). These recommendations, outlined in the SportSafe Australia: A National Sports Safety Framework include development and support for: • injury surveillance

• research

• education

• insurance

• culture

• sports safety plans

• sports first aid

• structured rules of games

• equipment (both provision of safe equipment and use of safety equipment)

• pre-participation screening. Tile VSIPP, as a State-wide structure to support a consistent

approach to reduce the prevalence and severity of injury, has three over-riding strategies to achieve this aim. These are: • Strategy One - Communication and Networking will embrace a

promotional campaign and advocacy for injury prevention, informat ion d isseminat ion and a process of educat ion and training, particularly targeting community sports clubs.

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• Strategy Two - Research and evaluation will support analysis of ex is t ing c o u n t e r m e a s u r e s , se t pr ior i t ies for r e s e a r c h and investigation and evaluate new and existing programs, resources, research and countermeasures .

• Strategy Three - Systems development and co-ordination will support a systematic approach to sports injury prevention in Vic tor ia , wi th l inks to key s t a k e h o l d e r s s u c h as Spo r t s Associations, local government and community networks. This s trategy will also develop strong links with inters ta te sports injury prevention programs and organisations. Sports injury countermeasures will be determined as par t of a

r i sk m a n a g e m e n t p r o c e s s . P r io r i t y s h o u l d be g iven to counte rmeasures tha t are most effective in reducing injury loss rather than based on causes of the accident. For example: • It may be more effective to promote the use of mouthguards in

order to reduce the effects of a collision rather than to minimise collisions in a contact sport.

• The use of a variety of countermeasures is more beneficial than the use of one main strategy for solving the problem.

• It is i m p o r t a n t to achieve quick posi t ive r e su l t s f rom the countermeasures. An example may be to have an entire football team purchase in-expensive over the counter mouthguards than to encourage the use of dental fitted mouthguards, which may be more effective but have a slower take-up rate.

• Economic factors should be considered as par t of the rationale for choice of option or countermeasure . Cost-benefit analysis should not be used for injury prevention as the value of the worth of a limb or eye is difficult to determine due to the effect on quality of life. However, cost-effectiveness designs minimise the cost to society. For example, one strategy, which may be more expens ive to implement , may be more cos t -ef fec t ive because it has the potential to reduce the rate of injury far more t h a n a less e x p e n s i v e c o u n t e r m e a s u r e . An example , contradictory of the previous one, is to promote dental fitted m o u t h g u a r d s r a t h e r t h a n p r o m o t e 'over the c o u n t e r ' mouthguards if it is determined that dental fitted mouthguards are more effective in reducing injury.

• Pass ive c o u n t e r m e a s u r e s are more benef ic ia l t h a n active countermeasures. The less reliant upon human behaviour, the less the c o u n t e r m e a s u r e is prone to fai lure. For example, building a stadium with a sprung floor may be a more effective countermeasure to reducing knee and ankle injuries than taping joints prior to a game.

• Consideration of the cultural, social and political forces will assist the success of the countermeasure (Thygerson, 1992).

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The Systems Approach vs the Individual Approach There are two areas of focus when determining the responsibility for injury prevention. One is locating the personal characteristics and behaviours of individuals (victim blaming), and the other is identifying the systems people find themselves in (systems blaming) (Hopkins, 1995).

The social, cultural and political environment of an individual may determine whether the approach is victim or system blaming. Victim blaming lends itself to a number of contributing factors including: lack of knowledge; gender; cul tural beliefs; political environment (economic rationalism v socialism) and personality (the notion of accident prone people). 'System blaming' approaches the environment and the system of organisation as the key contributing factors leading to injury. While it is easier in some respects to b lame the individual, due to less demand on government resources and the organisat ion having reduced responsibili ty, in many ways blaming the individual does not resolve the problem.

Removing the chance of human error, if there is scope to do so, is the preferred measure in injury prevention. Even if an extensive e d u c a t i o n p rog ram were u n d e r t a k e n to change i nd iv idua l behaviour, people continue to make mistakes. If the system is changed, then processes are implemented tha t do not rely on individuals remembering to follow a set of instructions (Hopkins, 1995). It should be noted, the most effective strategies do rely on a number of collective c o u n t e r m e a s u r e s , being envi ronmenta l , legislative and behavioural and should not be addressed in a simplistic manner to either a systems or individual approach. In the injury prevention field, the Haddon Matrix is one of the systems used as a blueprint to determine effective countermeasures.

Applying the Haddon Matr ix to reduce the f requency and severity of injuries William Haddon J r developed a system to identify risks and then apply one of 10 strategies, or a combination of these 10 strategies, to reduce the frequency and severity of injury. Haddon identified three phases that determine the occurrence of an injury. These are: • pre-event phase - events that determine whether an accident

takes place. This can also be described as events leading to an injury. One example may be a football player who is pushed into the fence by an opposing player resulting in a fractured leg. The blame may be a t t r ibu ted to the offending player. However, using Haddons' systems approach, if the boundary line were moved in, so tha t the fence becomes separated by distance, the injury is likely to be avoided or the result of an event may be less serious.

• event phase - this is the time of the event when the injury may occur. A countermeasures during the event phase to minimise

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Phases

Factors Pre-event Event Post Event

Fluid replacement, Pre-event I periodic warm-up Review rules, b'eabT~nt

Host (player) screening, kaining and stretching, mouthgards

Agent (court) Pre-court Sprung floors Mopping up sweat on inspection floor after collision

, ,H , H ,

Environment Padding at ends court walls (surrounds) Equipment design

Replace damaged equipment

Table 1: An example of the Haddon matrix as it appfies to basketball.

the t rauma may be wearing a mouth guard to reduce the chance of concussion or facial injury. The focus of the event phase is to reduce the impact or minimise the chronic effects of repetitive events.

• post-event phase - this phase emphasises to minimise the effects of the injury through early detection and effective rehabilitation. An example in sport is for clubs to have qualified sports trainers that can identify the severity of the injury and either apply the required t reatment or quickly refer the player to receive further t reatment from a qualified professional. The Haddon matrix involves placing these three phases and the

three epidemiological factors (human, agent, environment) together in a matrix that will enable countermeasures to be identified. Table 1 provides an example of the Haddon matrix applied to sport.

The c o u n t e r m e a s u r e s are deve loped u p o n H a d d o n ' s t en strategies. The ten strategies are often referred to as the hierarchy of control. One version outlined by Hopkins (1995) is: • elimination or substi tut ion of hazards

• engineering controls

• administrative controls

• personal protective equipment. These c o u n t e r m e a s u r e s are based upon the most effective

strategies, being passive, where decision making is eliminated, through to active measures which rely upon decision making to effect change (Thygerson, 1992). Passive measures are considered more effective due to the removal of human error. It should be noted that the hierarchy of control is rated on the most effective m e a s u r e of in jury cont ro l t h rough to the leas t effective and correlates to whether there is a rel iance upon human decision

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making. El iminat ion or subs t i t u t i on and engineer ing controls of hazards remove h u m a n error, subsequent ly removing the potential of an 'accident ' .

Conclusion It has been determined tha t sports injury has been recognised as a public heal th concern. Sport in Austral ia is worth 8 billion dollars a n n u a l l y a n d e m p l o y s over 9 5 , 0 0 0 peop le ( C o n f e d e r a t i o n of Aust ra l ian Sport, 1998). The subsequen t cost, economic and social, has an eno rmous impact u p o n our society. It is therefore in the interest of government and corporate bus iness to promote injury prevent ion in order to reduce associa ted costs and a t t rac t greater par t ic ipat ion in sport.

The VSIPP has a strategic role to play in spor ts injury prevention. By creat ing a support ive network th rough a top-down, bo t tom-up approach, and by providing direction based upon founded research, it is a n t i c i p a t e d t h a t b o t h s h o r t - t e r m goals of m a r k e t i n g a n d promot ion and the long-term goals of the reduct ion of injury in the spor ts communi ty will be achieved.

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Prevention Bulletin 17. Australian Institute of Health and Welfare National Injury Surveillance Unit. Adelaide.

Commonwealth Department of Human Services and Health. (1994). Better Health Outcomes for Australians. Commonwealth Department of Human Services and Health. Canberra.

Cheales, R. (1996). Risk management discussion paper. Queensland Office of Sport and Recreation, Brisbane.

Egger, G. (1990). Sports Injury in Australia: Causes, Costs and Prevention. A Report to the National Better Health Program. National Better Health Program. Canberra.

Health and Community Services Victoria. (1994). Taking Injury Prevention Forward: Strategic Directions for Victoria. Health and Community Services Victoria. Melbourne.

Northern Sydney Area Health Service. (1997). New South Wales Youth Sports Injury Report, July, 1997, Northern Sydney Area Health Service. Sydney.

Haddon, W. (1995). Energy damage and the 10 countermeasure strategies. Injury Prevention 1:40-4.

Hopkins, A. (1995). Making safety work: Getting management commitment to occupational health and safety. Allen & Unwin Pty Ltd. NSW.

Kreisfeld, R. (1998). The Injury Issues Monitor (Issue 12). Research Centre for Inj ury Studies of South Australia. Adelaide..

Routley, V. (1991). Sports injuries in children-The tie most commonly presented sports. Victorian Injury Surveillance System. Monash University Accident Research Centre. Hazard 9: December.

Routley, V. & Valuri, J. (1993). Adult sports injury. Victorian Injury Surveillance System. Monash University Accident Research Centre. Hazard 15: July.

Thygerson, A.L. (1992). Safety (2rid Edn). Jones and Barlett Publishers. Boston. Watson, W. & Ozanne-Smith, J. { 1997) The Cost of Injury to Victoria. Monash University

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