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Abstract
Objectives This study analysed sport and recreation-related fatalities in Québec, Canada, from January 2006 to December 2019, focusing on the six activities with the highest mortality frequencies. It aimed to identify activity-specific risk factors to inform prevention priorities.
Methods In this descriptive retrospective study, data extracted from the database of the Bureau du coroner du Québec were analysed. The characteristics and mechanisms of fatalities in all-terrain vehicles, snowmobiles, cycling, swimming, motorised navigation and non-motorised navigation activities were presented. Incidence rates were calculated using Canadian census data.
Results Male fatalities predominated, ranging from 83% to 91%, in the six activities. Traumatic brain injuries or cranial traumas were reported in 55.7% of land-based activities-related deaths, particularly in 70.1% of cycling fatalities. In 44.2% of cycling-related cases, victims were not wearing a helmet, while in 44.1% of cases involving all-terrain vehicles, victims either wore a helmet improperly or did not wear one at all. Cycling deaths mainly occurred on roads (82.9%), with 63.9% involving collisions with motor vehicles. Alcohol-impaired driving was observed in 29.8% of victims involved in all-terrain vehicle and snowmobile activities combined. Natural water accounted for 67.1% of swimming fatalities. Alcohol consumption was documented in 28.8% of deaths related to water-based activities. Personal flotation devices were not worn in 61.5% of navigation-related fatalities.
Conclusion Activity-specific prevention priorities have been highlighted. A thorough examination of coroners’ recommendations is now necessary to understand their characteristics, as this information can guide both the identification and implementation of preventive measures.
- Recreation / Sports
- Mortality
- Surveillance
Data availability statement
All data used were obtained from the computerised database of the Bureau du coroner du Québec. Requests for data use may be sent to the Bureau.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Over a 14-year period, there were 1937 unintentional injury deaths related to sport and recreation in the province of Québec, averaging 2.66 deaths per week, with six activities (all-terrain vehicles, snowmobiles, swimming, cycling, motorised navigation and non-motorised navigation) accounting for 80.2% of these fatalities.
Concentrating research endeavours, directing resources and implementing targeted interventions specifically on these few high-impact activities could potentially contribute more effectively to reducing the incidence of sport and recreation-related fatalities in Québec.
WHAT THIS STUDY ADDS
Most cycling fatalities involved traffic crashes, with almost half of the deceased not wearing helmets, and head trauma occurring in the majority of cases. Alcohol-impaired driving was noted in nearly a third of victims involved in all-terrain vehicle and snowmobile activities, while alcohol consumption was documented in 28.8% of deaths related to water-based activities. Personal flotation devices were not worn in 61.5% of navigation-related fatalities.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
The highlighted activity-specific prevention priorities will guide the selection and implementation of measures such as enhancing control over alcohol consumption in land motor sports and water-based activities, accelerating the development of dedicated bicycle infrastructure and promoting helmet use for cyclists and personal flotation devices for navigation activities, potentially through enforcement.
To further support this process, analysing coronial recommendations from death investigation reports can assist in identifying critical priority areas for action.
Introduction
Sport and recreation offer numerous physical and mental health benefits to individuals and communities.1 However, these activities also carry inherent risks, which can lead to tragic outcomes.2–4 Unintentional injury deaths related to sport and recreation represent a significant public health concern, warranting in-depth investigation and preventive measures.2–4
In the province of Québec, Canada, from January 2006 to December 2019, there were 1937 unintentional injury deaths related to sport and recreation, averaging 2.66 per week.4 Notably, six activities accounted for 80.2% of the total burden of the province and were linked to the highest population-based and participation-based death rates.4 In accordance with the Pareto principle,5 concentrating research endeavours, directing resources and implementing targeted interventions specifically on these few high-impact activities could potentially contribute more effectively to reducing the incidence of sport and recreation-related fatalities in Québec.4 These findings, drawn from a surveillance study that pertains to the first stage of the TRIPP (Translating Research Into Injury Prevention Practice) framework,6 underscore the need for a comprehensive understanding of the specific characteristics and mechanisms of these fatalities.
The second stage of the TRIPP framework aims to gain a thorough understanding of the aetiology of injuries and deaths.6 Although epidemiological studies may not directly elucidate all the putative causative factors of injury deaths, they can provide detailed information that can orient the identification of prevention strategies and research priorities.6 Accordingly, further investigation of unintentional injury deaths associated with sport and recreation in Québec is necessary to document the contributing factors related to fatalities in the most prevalent activities.4 This in-depth examination will contribute to informing the implementation, improvement and evaluation of adapted and activity-specific preventive measures.6 Moreover, comprehensive reporting of the characteristics of these deaths is crucial not only for identifying specific government prevention opportunities but also for potentially influencing the responses of sports organisations and participants.3
Therefore, this study examined the characteristics and mechanisms of sport and recreation-related fatalities in the six activities with the highest mortality frequencies, in Québec, Canada, from January 2006 to December 2019.
Methods
Design and data source
Building on prior research,4 this descriptive retrospective study used data from the computerised database of the Bureau du coroner du Québec (CD-BCQ), which provides standardised information for each death and uses a codification based on the International Classification of Diseases (ICD-10). Additional textual components can be found in the investigation reports. All investigated cases in this study were previously identified using algorithms based on preselected keywords and ICD-10 codes4 and procedures that specifically targeted cases coded by the coroners as ‘while playing a sport’ or ‘while participating in a game or leisure activities’.4 On data extraction, the completion rate for coroner investigations in 2019 was 96.2%, while the 2006–2018 period had reached a 100% closure. It is noteworthy that investigations reaching 95% completion or higher for a specific year typically occur around 3 years after its conclusion at the BCQ.4
Data processing
Two investigators thoroughly reviewed all 2791 coroner’s reports received from the BCQ and excluded all cases that did not qualify as ‘deaths in sport and recreation’ (n=557), as depicted in the data-flow diagram of a previous investigation.4 During a double data entry process, using exclusively the information in the coroners’ reports (no accompanying documents such as autopsy or police reports), the investigators precisely described the activity associated with each death, collected relevant data on the place of occurrence, context, protective equipment, victims’ swimming skills, consumption of alcohol or other psychoactive substances (non-alcohol drugs) and traumatic brain injuries7 or cranial traumas (TBI-CT) following the detail description provided in the data processing section of earlier research.4 For psychoactive substances to be marked as ‘positive’ in the database, toxicological tests, as indicated in the investigation reports, had to confirm the presence of one or more of the following three categories: (1) non-alcohol illicit drugs, (2) cannabis (legalised on 17 October 2018) or (3) pharmaceuticals explicitly identified by the coroner as potentially psychoactive.
The final dataset consisted of 2234 sport and recreation-related deaths: 297 natural deaths and 1937 unintentional injuries, including 761 drowning deaths.4 The current study focused on investigating the characteristics and mechanisms of the six activities that accounted for 80.2% of the total burden of unintentional injury deaths: all-terrain vehicles (ATVs, n=383), snowmobiles (n=348), swimming (n=286), cycling (n=274), motorised navigation (n=151) and non-motorised navigation (n=111).4 Within these activities, drowning deaths were identified, using ICD-10 codes in conjunction with textual information found in the coroner’s reports.4 The research did not require ethical approval as it relied exclusively on publicly available information. Under the Coroners Act (CQLR, chapter C-68.01), coroners’ reports are public records.8
Statistical analysis
Population-based rates were calculated using age and sex estimates for Québec’s administrative regions as of 1 July of each year, extracted from the Institut de la statistique du Québec’s website.9 They were presented per 100 000 person-years and reflect the annual death count relative to the corresponding year’s population. High concordance was found between crude and age-adjusted (17 and under, 18–44 years, 45–64 years, 65 and over) and sex-adjusted annual incidence rates.4 Thus, only crude rates are presented.2 4 CI at a 95% significance level were computed using the Gamma distribution method.10 Following Statistics Canada guidelines, estimates with coefficients of variation (CVs) exceeding 33.3% were labelled unreliable (marked as ‘F’ in the tables). Estimates having CVs between 16.6% and 33.3% were also identified and necessitate cautious interpretation.11 12 The analysis was conducted by using SAS software (2019–2020, SAS Institute).
Results
Male fatalities were predominant in the six analysed activities, ranging from 83% in cycling to 91% in motorised and non-motorised navigation.
ATVs and snowmobiles
For ATVs, death rates stand out in individuals aged 18–24 years and 12–17 years (0.56 and 0.53 per 100 000 person-years, respectively), compared with all age groups (table 1). Non-traffic incidents accounted for 58.2% (n=223) of ATV-related deaths and 76.4% (n=266) of snowmobile-related deaths. Victims did not wear a helmet, or it was documented as ‘worn improperly, inadequate or poorly fixed’, in 44.1% (n=169) of ATV incidents, and in 11.5% (n=40) of snowmobiles-related deaths. TBI-CT were reported in respectively 51.7% (n=198) and 48.9% (n=170) of ATV and snowmobile-related deaths. Among the 169 deceased ATV users not wearing helmets (or not wearing it properly), 114 (67.5%) had a documented TBI-CT. Of the 94 individuals wearing helmets correctly, 45 (47.9%) had a documented TBI-CT. Among the 40 deceased snowmobile users not wearing helmets or wearing them improperly, 26 (65%) had documented TBI-CT. Among the 139 correctly wearing helmets, 87 (62.9%) had a documented TBI-CT (data are not shown).
Numbers, population-based rates and characteristics for all-terrain vehicles and snowmobile-related deaths in Québec, Canada, 1 January 2006–31 December 2019 (inclusive)*
Blood-alcohol concentration (BAC) exceeded 80 mg/100 mL (legal threshold for driving in Québec) in 32.4% (n=124) and 30.5% (n=106) of victims of ATV and snowmobiles-related deaths respectively. Out of these alcohol-impaired victims, respectively, 94.4% (n=117) and 95.3% (n=101) were drivers (data are not shown). The presence of other psychoactive substances was documented in 17% (n=65) and 14.9% (n=52) of the deaths associated with ATV and snowmobiles activities. Among these, 93.9% (n=61) and 92.3% (n=48) were drivers, respectively (data are not shown).
Swimming
Death rates for individuals aged 18–24 years notably emerge as the highest (0.59 per 100 000 person-years) when considering all age groups (table 2). Drowning and submersion in natural water environments (W69 and W70) accounted for 67.1% (n=192) of swimming fatalities. Drowning victims who represent 97.6% (n=279) of all swimming deaths, had no swimming skill or were documented as weak swimmers in 31.5% (n=88) of the cases, and 26.5% (n=74) of them were alone at the time of the incident. The presence of alcohol (in all amounts) or other psychoactive substances was documented in, respectively, 31.8% (n=91) and 16.8% (n=48) of swimming-related deaths. BAC exceeded 80 mg/100 mL in 19.2% (n=55) of all swimming fatalities.
Numbers, population-based rates and characteristics for swimming-related deaths in Québec, Canada, 1 January 2006–31 December 2019 (Inclusive)*
Cycling
Most cycling deaths (82.9%, n=227) occurred on roads (table 3). In 63.9% of cases (n=175), the cyclist was involved in a traffic crash, either colliding with a car, pickup truck or van (V13.4, 47.1%, n=129), or with a heavy transport vehicle or bus (V14.4, 16.8%, n=46). No helmet was worn in 44.2% (n=121) of cycling fatalities. TBI-CT were reported in 70.1% (n=192) of cycling-related deaths. Among the 121 deceased cyclists not wearing helmets, 103 (85.1%) had a documented TBI-CT. Of the 54 individuals wearing helmets correctly, 29 (53.7%) had a documented TBI-CT (data are not shown).
Numbers, population-based rates and characteristics for cycling-related deaths in Québec, Canada, 1 January 2006–31 December 2019 (inclusive)*
Motorised and non-motorised navigation
Personal flotation device was neither worn nor worn properly in, respectively, 66.2% (n=100) and 68.5% (n=76) of all motorised and non-motorised navigation-related deaths. When considering both activities together, personal flotation device was not worn in 61.5% (n=161) of the deaths. Drowning victims who represent 92.1% (n=139) and 95.5% (n=106) of all motorised and non-motorised navigation-related deaths, respectively, had no swimming skill or were documented as weak swimmers in 15.1% (n=21) and 22.6% (n=24) of the cases. Drowning victims were alone at the time of the incident in 35.3% (n=49) of the deaths in the former activity and in 33% (n=35) in the latter.
Alcohol consumption was documented in 25.2% (n=38) of motorised navigation and in 26.1% (n=29) of non-motorized navigation-related deaths. BAC exceeded 80 mg/100 mL in, respectively, 15.2% (n=23) and 18% (n=20) of all cases associated with these activities. The presence of other psychoactive substances was documented in, respectively, 10.6% (n=16) and 27% (n=30) of the deaths (table 4).
Numbers, population-based rates and characteristics for motorised and non-motorised navigation-related deaths in Québec, Canada, 1 January 2006–31 December 2019 (inclusive)*
Discussion
This study identified activity-specific risk factors, offering crucial insights for prioritising prevention efforts to ultimately reduce mortality. In land-based activities, the concerning prevalence of cycling victims not wearing helmets and of ATV victims with improperly worn or absent helmets demands attention. TBI-CT were observed in 70.1% and 51.7% of fatalities in these respective activities. Wearing a helmet while cycling is particularly effective in preventing severe head injuries, with increased benefits in high-risk situations and when cycling on shared roads, as evidenced by a systematic review of meta-analyses.13 In the current study, 82.9% of cycling deaths occurred on roads and 63.9% of all cycling fatalities involved collisions with motor vehicles. Moreover, the prevalence of documented TBI-CT was higher among cyclists not wearing helmets (85.1%) compared with those wearing them (53.7%). This underscores the critical importance of helmet-related incentives, especially since helmet use while cycling is not mandated by law in Québec. Besides, various preventive measures have been explored to enhance cyclist safety on shared roads, including legislation or advertising campaigns to increase helmet use, interventions to improve cyclist visibility, and environmental and infrastructure adaptations.13–18 Interestingly, separate bicycle infrastructures, such as cycling lanes and paths, are suggested to influence both participation levels and cyclist safety.15 While the province is already taking steps to improve cycling safety, prioritising and expediting the implementation of separate bicycle infrastructures seems crucial. Removing cyclists from direct contact with motor vehicles inherently reduces the risk of collisions, making it a highly effective strategy. To maximise effectiveness, preventive measures implemented in concert,13–16 such as legislated helmet use and maximising cycle path development, seem to be tailored to address the challenges of Québec’s landscape. Regarding ATVs, under the Protective Helmets Regulation of the Act respecting off-highway vehicles (CQLR, chapter V-1.3; c-24.2, r. 6),19 all operators and passengers must wear helmets with visors that meet regulatory standards. However, enforcement of this regulation may present challenges, as more than half of ATV fatalities occurred in non-traffic crashes. Increasing the proportion of riders who wear helmets seems crucial, however, since TBI is more common among unhelmeted riders, and helmet use was suggested to substantially decrease the mortality and morbidity in ATV-related crashes.20 In the current study, ATV users wearing helmets showed a lower percentage of TBI-CT (47.9%), compared with those who did not wear helmets or wore them improperly (67.5%). Hence, ongoing endeavours to raise awareness, coupled with heightened and stringent law enforcement, could represent the most promising strategies for promoting helmet usage and improving safety consciousness among ATV users.
Alcohol consumption in ATV and snowmobiles users in Québec is also a legislated19 risk factor that demands attention.21 In the current study, nearly one-third of the victims engaged in these activities had a BAC exceeding the legal threshold for driving. Notably, almost all these intoxicated individuals were driving. Hence, heighten efforts to continually evaluate, improve and complement existing preventive strategies in Québec, such as legislated alcohol limits and mass media campaigns to discourage impaired driving, are warranted. Furthermore, the study revealed that 16% of ATV and snowmobile victims (n=117), including 14.9% of drivers (n=109), were noted to have used other psychoactive substances. This deserves consideration, as these substances are associated with an increased risk of road traffic crashes.22 Therefore, similar to helmet use, implementing intensified and strict law enforcement measures could also enhance the prevention of impaired driving among off-road vehicle users. Notably, however, snowmobile and ATV activities exhibited the highest participant-based death rates (2.51 and 1.69 per 100 000 participant-years, respectively) among all sport and recreation activities in Québec.4 Despite their popularity, they do not offer as many cardiovascular benefits as more physically demanding activities,23 thus presenting a disadvantageous risk–benefit profile. Analysing this ratio allows researchers, policy-makers and individuals to make informed decisions about which leisure activities to engage in and promote, considering both the health benefits and the level of risk.
The fact that personal flotation devices were not worn in 61.5% of motorised and non-motorised navigation-related deaths is worth highlighting, given that the prophylactic potential of these devices necessarily depend on their utilisation.24 The Canadian law only requires each person to have a device on board. Interestingly, compulsory personal flotation device-wearing regulations in Victoria, Australia, were associated with an increased usage and a decreased recreational boating drowning deaths, thereby providing support for the adoption of such a regulatory approach in other jurisdictions.25 Moreover, alcohol consumption was documented (in all amounts) in 28.8% of the deaths in the three water-based activities. This should draw attention since alcohol represents a major risk factor when associated with aquatic activities26 or driving.27 This applies equally to other psychoactive substances27 since they were documented in over a quarter of non-motorised navigation-related deaths.
Almost all motorised navigation, non-motorised navigation and swimming-related deaths were drownings, thereby constituting 68.9% (n=524) of all drownings associated with sport and recreation.4 While it is expected that natural or open water bodies would be associated with deaths in navigation activities, it is noteworthy that they accounted for 67.1% of swimming-related fatalities, emphasising the importance of targeting prevention efforts toward open water bodies. Drowning victims in motorised navigation, non-motorised navigation and swimming activities lacked swimming skills or were documented as weak swimmers in a significant proportion of cases. Nonetheless, to enhance drowning prevention with measures such as mandatory school swimming lessons, assessing the impact of heightened water exposure is critical due to its substantial role in drowning risk.28 Evaluating potential effects on individuals’ risk-taking behaviour is equally imperative. In Victoria, Australia, drowning was identified as the most common cause of death attributable to sport and recreation from 2001 to 200729 and from 2005 to 2015.2 In Québec, it contributed to 39.3% of all sport and recreation fatalities from 2006 to 2019.4 The current study found that the vast majority of deaths in the three analysed water-based activities were males, with drownings accounting for almost all of these fatalities. Previous investigations suggest that males’ greater exposure to aquatic activities could partly explain their high representation in drowning incidents.30 Furthermore, males were found to overestimate their swimming ability and to take greater risks in aquatic settings, including drinking alcohol, swimming alone and swimming in natural bodies of water.30 Alcohol may impact confidence and risk-taking30 and has been identified as the most important single contributing factor in adult drowning.26 Additionally, men who were drinking and powerboating were less likely to wear a life jacket than those who did not.30 Psychoactive drugs may similarly affect risk-taking and have potential deleterious effects on swimming ability (psychomotor function and cognition) and survival possibilities in activities with drowning potential.27 31 32 Therefore, preventive measures related to consumption of alcohol and psychoactive substances in male boaters and swimmers should represent a priority area of intervention and investigation.27
These findings should guide the development of targeted preventive strategies to enhance safety in sport and recreation in Québec as part of the third stage of the TRIPP framework.6 Subsequent stages involve evaluating the effectiveness of these measures and their feasibility within the provincial context, with the final step centred on real-world implementation and effectiveness assessment.6
Strengths, limitations and perspectives
The broad scope of the CD-BCQ and the rigorous data entry process are strengths of the study.4 Limitations include the coroners’ widespread use of the term ‘polytraumatism’ which may have led to an underestimation of TBI-CT, and the potential inflation or deflation of BAC in cadavers that have been submerged in water for an extended period.33 However, it has been suggested that postmortem ethanol production may have a limited impact on research addressing the prevalence rate for alcohol-related drownings.26 Moreover, other psychoactive substances were recorded using the information available in the investigation reports (no toxicology reports): amounts were not available in most coroners’ reports, and the presence of metabolites does not imply that the substance contributed to the event.22 34 Finally, to obtain a comprehensive understanding of mortality in sport and recreation, further investigations will be required, specifically focusing on coronial recommendations and natural deaths.
Conclusion
This study identified activity-specific risk factors to consider when setting prevention priorities and developing adapted preventive measures in Québec. It demonstrated that most cycling fatalities involved traffic crashes, with almost half of the deceased not wearing helmets and head trauma occurring in most cases. Alcohol-impaired driving was observed in nearly a third of victims involved in ATV and snowmobile activities, while alcohol consumption was documented in 28.8% of deaths related to water-based activities. Personal flotation devices were not worn in 61.5% of navigation-related fatalities. Investigating coroners’ recommendations will complement the process of identifying prevention opportunities. These findings should inform the development, improvement, evaluation and implementation of targeted preventive strategies.6
Data availability statement
All data used were obtained from the computerised database of the Bureau du coroner du Québec. Requests for data use may be sent to the Bureau.
Ethics statements
Patient consent for publication
Acknowledgments
The authors would like to thank Judith Lahiri-Rousseau, Jonathan Phimmasone, Emilie Belley-Ranger, Maxime Charbonneau and Claude Goulet for their insights and technical support, as well as Alexis Leuterio for the linguistic revision. The authors extend their appreciation to the Direction de la Sécurité dans le Loisir et le Sport and the Ministère de l’Éducation du Québec, who will subsequently publish a report based on the study’s results. The authors declare no conflicts of interest, financial or otherwise.
References
Footnotes
Correction notice This article has been corrected since it was first published online. Tables 1 and Tables 4 have been swapped, to correct an earlier publication error.
Contributors PR planned the study, was responsible for its conceptual framework and managed the project. All authors contributed to the conception and design of the study. PR and P-AP collected the data. JS-M conducted the analysis. PR, JS-M and MG planned and revised the analysis and interpreted the results. PR drafted the manuscript. All authors critically revised and edited the manuscript. PR submitted the study and is the guarantor.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.