Common Cause

Are the Cultural Conditions for Increasing Physical Activity and Injury Reduction Mutualistic?

With declining physical activity levels being cited as a major health threat in North America, there is an increasing interest in the role that sport can play in reversing this trend, but the challenge is great since patterns of behavior are notoriously difficult to change. Physical activity is positively associated not only with positive health outcomes but also with physical injury. It also is becoming increasingly clear that the implementation of many injury reduction protocols also require behavioral changes that are challenging to effect. Finch (²) has proposed a revised framework for designing injury prevention programs in sport that addresses this issue among others at “Stage 5” of the framework.

Individual behavioral patterns are determined by a complex mix of inherited factors and learned behaviors. Both of these factors are potentially active on both sides of the health outcome ledger. Inherited characteristics like the personality factor “thrill and adventure seeking” contribute to the motivation to participate in a sport and also are associated with behaviors that increase the risk for physical injury (⁷). The particular experiences an individual has will partially determine whether he or she will come to practice a sedentary or active lifestyle and, if active, the habits he or she will adopt, which will contribute to injury risk.

In regard to learned behaviors, it is important to recognize that the meaning an individual attaches to a particular experience is partially determined by the culture in which the person is immersed. Because culture can be deliberately manipulated, we can change individual behaviors, such that undesired ones become sanctioned and desired ones become rewarded. In contrast, the influence that inherited traits have on motivational dispositions cannot be readily manipulated. Where their influence is undesirable, we can, however, reduce risk by creating safer outlets for their expression.

From a public health perspective, a balanced risk management strategy for physical activity needs to take account of both sides of the health ledger: injury prevention and activity promotion. Any innovation that can encourage more physical activity or reduced injury within a population should count as success. The best interventions will contribute to both. Because the factors that determine unhealthy or risky behavior are operational on both sides of this ledger, injury prevention and activity promotion might be profitably considered within a single model. An example of such a mixed approach may be the avalanche safety programs in Western Canada.

The Canadian Avalanche Association began providing avalanche forecasts in 1992 and began training for nonprofessionals in 1997. The effort has since been intensified with active media engagement and special public warnings during periods of high hazard. The two largest nonprofessional populations exposed to avalanche risk are snowmobilers and people engaged in human-powered sports such as backcountry skiing. Because these activities are entirely unregulated and uncontrolled, any behavioral change must be voluntarily assumed by the participants themselves.

By 2007, most human-powered nonprofessionals had taken training (⁵). They also had experienced a decline in the incidence of avalanche fatalities and an increase in participation intensity, as measured by days of activity per person and energy expended per day. There is compelling anecdotal evidence that the active population also has grown. The snowmobile population has, until very recently, not taken training and has not seen an improvement in avalanche associated mortality, although all the same interventions are available to it (¹).

The relationship between training and avalanche risk reduction seems to be complex. A cross-sectional comparison found that training level is associated with increased avalanche risk because trained people exploit their knowledge to gain access to higher-quality experiences and to participate more intensely (⁵). However, training also may change the risk culture by raising awareness of avalanche risk across the population and so encouraging the behavioral changes that enable the risk reduction observed longitudinally. That this change takes time is to be expected. Behavioral change on the part of an individual is hard to achieve and is unlikely to persist unless it is supported by cultural changes that take time to occur.

The critical psycho/social causal factor is the weight assigned to avalanche danger because the weight assigned affects the balance of pros and cons attached to any particular decision. Increased weight would encourage people to sacrifice some quality of experience to reduce risk, but it also may have other effects such that:

• – Behaviors that reduce risk but are burdensome to perform are more likely to be exhibited. An example is regular companion rescue practice that increases the chance of live recovery after a burial. Notably, a Canadian is likely to be excavated almost twice as fast as a European (³).
• – Participants place higher value on acquiring knowledge and data that enable them to make more informed decisions. This knowledge enables people to recognize terrain and snow condition opportunities better for high-value experiences that carry reduced risk.
• – Safe behaviors acquire value in their own right such that community members apply status to those who practice them and sanction on those who do not. For example, it has recently become common practice for people to refuse to ski back-country with people who have not practiced their companion rescue skills.

These changes in behavior reflect changes in the culture of the at-risk community. There is a considerable body of literature on “safety culture” as it applies to large organizations (⁶) and the conditions thought to promote strong safety cultures in an organizational setting seem to have been present for the human-powered group but largely absent for the snowmobile group. Relevant factors include the following:

• – Respected leadership: Avalanche professionals traditionally have been members of the human-powered group. Avalanche course participants report a high level of trust in the advice given by these professionals. By contrast, snowmobilers have had little regard for the human-powered group (personal communication).
• – Espousals match enactments: Avalanche professionals model the behavior that they advocate, but only for their human-powered community because each group recreates separately. By “walking the talk,” leaders validate by word and deed the pursuit of experiences that satisfy inherited traits like thrill and adventure seeking and the recommended strategies for reducing avalanche risk. By validating behaviors that satisfy both sides of the health promotion ledger, they also build respect for their leadership.
• – Internally consistent policy: While the various demands for safe behavior may conflict with each other and/or with the desire for high-quality experiences, heuristics have been created to help resolve conflicting demands. This methodology was built for human-powered activities and works poorly for snowmobilers who use avalanche terrain differently.
• – Respectful messaging: Avalanche professionals discuss their own vulnerability to avalanche hazard while espousing human-powered activities as being valid pursuits. By contrast, snowmobilers report that “advice” from human-powered experts sounds condescending and arrogant. This type of messaging is known to result in a process of “neutralization” that promotes risk denial with respect to the hazard (⁴).

Of relevance is the winter of 2002/2003, which saw a historical high of 19 deaths in the nonprofessional human-powered group, including the deaths of seven schoolchildren. The reversal in the fatality incident trend might be solely attributable to these events if the decline had been immediate and followed by an increase as memories faded, which is not the case. Also, other serious incidents that happened previously did not result in observable declines in the incident rate. More likely is that because the conditions for a strengthened safety culture already existed, these events provided the catalyst for cultural change.

The snowmobile group experienced a catastrophic winter in 2008/2009 with 19 fatalities. In the following season, approximately 240 snowmobilers were avalanched at an unsanctioned event resulting in two fatalities. The events occurred just as the conditions required for a snowmobile safety culture were falling into place. In particular, early adopters from the snowmobile group had become avalanche experts that could lead a culturally sensitive safety program that had been redesigned to fit the specific needs of this group. Early signs are that the incidence of fatalities is now declining for snowmobilers too.

Conclusion

Since the determinants of behavior are common to injury prevention and the promotion of physical activity, these two objectives should be considered within a single health promotion model. Developing methodology for such an approach may be informed by reference to the factors thought to encourage strong safety cultures in an organizational setting and the Translating Research into Injury Prevention Practice (TRIPP) framework proposed by Finch (²). An advantage of this approach may be that engineering cultural changes that support injury reduction may support activity promotion and vice versa.

The author serves as the executive director for Outdoor Council of Canada (Conseil canadien de plein air).