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Recreational tourism injuries among visitors to New Zealand: an exploratory analysis using hospital discharge data
Tourism Management 22 (2001) 373}381
Recreational tourism injuries among visitors to New Zealand: an exploratory analysis using hospital discharge data Tim Bentley , Denny Meyer, Stephen Page *, David Chalmers Centre for Occupational Human Factors Ergonomics, Forest Research, Sala Street, Private Bag 3020, Rotorua, New Zealand Department of Statistics, Massey University-Albany, Private Bag 102 904, Auckland, New Zealand Department of Marketing, University of Stirling, Stirling, Scotland FK9 4LA, UK Injury Prevention Research Unit, Department of Preventive and Social Medicine, University of Otago, PO Box 913, Dunedin, New Zealand Received 8 November 1999; accepted 26 May 2000
Abstract New Zealand Health Information Service (NZHIS) morbidity data for the 15-year period, 1982}1996, were analysed to determine the role of recreational and adventure tourism in overseas visitor injuries, and identify recreational activities with greatest injury occurrence. Approximately 19 per cent of all injuries involved recreational/adventure tourism activities, corresponding to 8.4 injuries per 100,000 overseas visitor arrivals. This "gure can be compared to that for motor vehicle tra$c accidents (12), and suggests a signi"cant recreational tourism injury problem in New Zealand. Injuries were concentrated in regions known to be major centres for adventure tourism in New Zealand, and were most commonly sustained by overseas visitors aged between 20 and 40 years. Tourist injuries were observed most frequently for activities that involve independent, unguided recreation, notably skiing, mountaineering and tramping. Of the commercial adventure tourism activities, horse riding and cycling were the only signi"cant contributors to overseas visitor injuries. 2001 Elsevier Science Ltd. All rights reserved. Keywords: Adventure tourism; Recreational tourism; Tourist safety
1. Introduction The health needs of international tourists place a considerable burden on the health and safety services of tourism destinations (Wilks & Oldenburg, 1995; Nichol, Wilks, & Wood, 1996). As destinations such as Australia and New Zealand experience considerable growth in their tourism markets, there is an increasing need to understand the health and safety needs of overseas tourists. Central to achieving this understanding is the identi"cation of health and safety problems most frequently experienced by overseas visitors (Wilks & Atherton, 1994; Bentley, Page, & Laird, 2000). International research has consistently recognised unintentional injury as a leading cause of tourist morbidity and mortality (Hartung, Goebert, Taniguchi, & Okamoto, 1990; Guptill, Hargarten, & Baker, 1991;
* Corresponding author. Tel.: #44-1786-466451; fax: #44-1786464745. E-mail address: [email protected] (S. Page).
Hargarten, Baker, & Guptill, 1991; Paixao, Dewar, Cossar, & Reid, 1991; Nichol et al., 1996; Page & Meyer, 1996, 1997; Wilks, 1999). Moreover, tourists appear more likely to be injured or killed as a result of incidents while overseas than when in their country of residence (Hargarten et al., 1991), and international visitors require hospitalisation due to injury more commonly than interstate visitors or local residents (Nichol et al., 1996). Despite these "ndings, the tourist safety literature is very limited. It does, however, o!er a number of explanations for this increased injury risk amongst overseas travellers. These can be broadly grouped into the following factors: E exposure to unfamiliar road, marine, mountain, wilderness and built environments (Johnston, 1989; Guptill et al., 1991; Philipp & Hodgkinson, 1994; Wilks & Atherton, 1994; Wilks & Watson, 1998); E increased time spent engaged in activities for which there is a risk of injury, particularly driving (Wilks, Watson, & Faulks, 1999); E exposure to unfamiliar activities such as driving on the other side of the road (Guptill et al., 1991; Page
0261-5177/01/$ - see front matter 2001 Elsevier Science Ltd. All rights reserved. PII: S 0 2 6 1 - 5 1 7 7 ( 0 0 ) 0 0 0 6 3 - 7
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& Meyer, 1996; Wilks et al., 1999), marine tourism (Wilks & Atherton, 1994) and adventure tourism (Page & Meyer, 1996, 1997; Bentley et al., 2000); E relaxed attitudes towards risk and reduced inhibitions among holiday-makers (Cossar et al., 1990; Philipp & Hodgkinson, 1994; Ryan, Robertson, & Page, 1996). Tourist accidents can have a profound e!ect on the image of a country's tourism industry, and the selection of tourist destinations by potential holiday-makers (Bovet, 1994; Wilks, Pendergast, & Service, 1996; World Tourism Organisation, 1996). Nowhere is this better illustrated than in the adventure tourism industry, for which major negative events, such as the 1999 canyoning incident in Switzerland, can have signi"cant long-term social and economic impacts on the industry and communities whose economies are dependent upon tourism. Adventure tourism is a rapidly expanding sector of the New Zealand tourism industry (Berno & Moore, 1996), and an increasing number of visitors seek adventure activity during their stay in New Zealand (Major, 1995). There is growing evidence that adventure and recreational injuries make a signi"cant contribution to overseas visitor morbidity and mortality in New Zealand (Bentley et al., 2000; Page & Meyer, 1996, 1997). Moreover, some New Zealand adventure activities, notably white water rafting, scenic #ights and mountain recreation, appear to present signi"cant risks of serious and fatal injury to clients (Johnston, 1989; Hall & McArthur, 1991; McLaughlan, 1995; Greenaway, 1996). Recent research by the present authors, however, has suggested that it is adventure activities with lower levels of &perceived risk' associated with them which may have highest &actual' injury risk, when all levels of injury severity are considered. Some 142 New Zealand adventure tourism operators, representing 21 di!erent activity sectors, were asked by postal questionnaire to document the number of minor and serious injuries experienced by clients of their activity during the previous 12-month period. Using activity exposure data supplied by operators (duration of activity and travel to and from activity location), client injury-incidence rates were determined for each activity sector. Highest client injury-incidence rates were found for cycle touring, quad biking, horse riding and caving (Bentley et al., 2000). The authors note that operators reporting the highest incidence of injuries o!ered activities which involved the risk of falling from a height whilst in motion. Furthermore, activities with highest reported incidence of injury came from sectors which did not have a high level of perceived risk associated with them, did not come under the jurisdiction of any government authority, and were not the subject of any regulatory code of practice. The present study builds on this work, considering the role of recreational and adventure tourism in public hospital injury admissions for non-New Zealand resi-
dents (overseas visitors to New Zealand) over a 15-year period: 1982}1996. The aims of the study were to quantify the role of recreational activities in overseas visitor hospital admissions, to compare recreational tourism with motor vehicle tra$c accidents as a major cause of overseas visitor morbidity, and to identify recreational activities for which highest frequencies of injuries were sustained.
2. Method The data source used was the Ministry of Health's New Zealand Health Information Service (NZHIS) public hospital morbidity data "les, routinely collated on all discharges from public hospitals. The data set contained information about all non-resident discharges from public hospitals throughout New Zealand, for the period 1982}1996. The large majority of cases included in the analysis were tourist injuries, with a small but unknown proportion of cases involving non-residents working o!shore (mostly "shing and other vessel crew), and persons working in New Zealand on overseas visitor work permits. Table 1 gives details of variables considered in the analysis, together with an explanation of how each variable was derived from the data set, and whether variables had missing cases (variables were only considered where data were available for more than 50 per cent of cases). The circumstances of injuries were coded according to the International Classi"cation of Diseases: External Causes of Injury and Poisoning (Commission on Professional and Hospital Activities). The numerous 3-digit E-code values found within the data set were collapsed into 17 event groups, providing a variable more suitable for analysis. For example, the event group &falls from a height' and &falls on the level' was derived from E-codes 880}888, and included E-codes denoting &fall on or from stairs or steps', &fall into hole or other opening in surface', and &fall from one level to another' and &fall on the same level from slipping, tripping, or stumbling'. Recreational tourism activities were identi"ed from content analysis of the &one-line' event descriptions. Thus, for relevant event group categories (i.e. motor vehicle non-tra$c accidents; cycles; animals; watercraft; aviation; falls from a height and on the level; struck by/strike against object or person), the &one-line' descriptions of accident circumstances were examined to determine the involvement of recreational activities. Where insu$cient information was contained in the &one-line' event descriptions, cases were recorded as &unspeci"ed' (e.g. &unspeci"ed boat/ship'; &unspeci"ed aircraft' as detailed later in Table 3). The geographical location of overseas visitor injuries within New Zealand had to be determined indirectly from information on the hospital to which the injured
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375
Table 1 Variables considered in the analysis of overseas visitor injuries Variables considered in the analysis
Where data were derived
Example of variable
Missing cases
Place of occurrence
Location code
Yes
Event
First 3 digits of E-code
Recreational/adventure tourism activity
Event description (&one-line' description of injury circumstances provided in narrative "elds) Number of days stay in hospital Injury severity score code
Farm, road, place for sport or recreation, home Motor vehicle tra$c accident, watercraft, fall on the level, animal &hang glider blown to ground'; &fell while skiing'; &thrown from a horse' 2 days 1"minor, 2"moderate, 3"serious, 4"severe Hospital number (e.g. Dunedin, Christchurch) 1982}1996 January Precise age of injured visitor Male
No Yes
Hospital days Injury severity score Geographical region
Hosptial code of hospital injured visitor was admitted to Year of discharge Month of injury Age Gender of injured visitor
Year of injury Month of injury Age group Gender
Table 2 Overseas visitor injury incidence: 1982}1996 Year
Overseas visitor arrivals (;10)
Hospital admissions n
1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 Total
472.6 487.7 518.4 570.0 689.1 763.2 855.5 867.5 993.4 967.1 999.7 1086.6 1213.3 1343.0 1441.8
173 245 243 291 304 379 310 383 444 423 492 589 606 454 527
13,268.9
5863
Injury-incidence rate
% 3.0 4.2 4.1 5.0 5.2 6.5 5.3 6.5 7.6 7.2 8.4 10.0 10.3 7.7 9.0 100
37 50 47 51 44 50 36 44 45 44 49 54 50 34 37
No No
No No Yes No No
Data on the nationality of injured overseas visitors were insu$ciently complete to undertake a worthwhile analysis, this being a major limitation of the study. Data were prepared for analysis as described above, and descriptive analysis of the data set was undertaken using SAS Version 6.12. Crosstabular analysis and correspondence analysis (Greenacre, 1984) were applied as appropriate to the variables described in Table 1. Correspondence analysis is a multidimentional scaling method for spatially portraying categorical data, originally expressed as crosstabulations. Row and column labels are represented as points in a joint space in which interpoint distances can be related to the row}column association (Greenacre, 1984).
3. Results 3.1. Incidence of overseas visitor hospital admissions: 1982}1996
44
Source: Statistics New Zealand. Injuries per 100,000 arrivals.
person was admitted. The many hospital codes found in the data set were collapsed into 16 regional groups to allow for a manageable analysis of the spatial distribution of injury events. This method of identifying event location will have produced a small but unknown degree of error, as patients may, in some cases, have been transferred to hospitals in other regions, or may have been admitted to hospital later in their holiday as the extent of their injury became apparent. Nevertheless, it is reasonable to assume that the location of the incident would, in most cases, correspond to the hospital of admission.
Some 5863 overseas visitors were admitted to New Zealand public hospitals as a result of injury during the 14-year period, 1982}1996. Injury-incidence rates (per 100,000 overseas visitor arrivals) were calculated for each year, 1982}1996, and are shown in Table 2. No notable trends across time were observed for overseas visitor hospital admissions, although data for 1995 and 1996 suggest that injury rates may be falling. The overall incidence rate of 44 injuries per 100,000 overseas visitor arrivals indicates that approximately one in every 2300 overseas visitors was admitted to hospital with an injury during their stay in New Zealand. Many of these cases did not involve serious injuries, however. Indeed, one-half of visitors were hospitalised for a period of two days or less, while 80 per cent spent less than 10 days in
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Table 3 The role of recreational and adventure tourism in overseas visitor injury morbidity: 1982}1996 Event group
n
Motor vehicle tra$c Motor vehicle non-tra$c Pedal cycle
1604 59 165
%
27.4 1.0 2.8
Animal-related
174
3.0
Watercraft-related
320
5.5
Aviation-related
100
1.7
Falls from a height/falls on the same level
2027
34.6
Struck by/strike against object or person
325
5.5
Other (non-recreational events)
1089
18.6
Total
5863
100
Recreational/adventure tourism activities
Quad/farm bikes Road cycling Mountain biking Other/unclassi"ed Horse (fell from) Horse (kicked by) Bull (rodeo) White water raft Jet boat Kayak/canoe Diving Crew/"shing boat Unspeci"ed boat/ship Parapenting/gliding Skydiving Glider/unpowered Hang glider Crew/work-related Unspeci"ed aircraft Helicopter Skiing/snowboarding Mountaineering/tramping Luge Flying fox Parapenting White water rafting Playground activity Swimming pool/spa Skiing/snowboarding Mountaineering/tramping Rugby/other sports
Total estimated adventure tourism
n
%
18 95 13 57 153 18 3 46 21 3 3 115 132 27 23 5 4 4 24 13 344 260 24 18 9 5 40 27 20 10 108
1027
30.5 57.6 7.9 34.5 87.9 10.3 1.8 14.5 6.6 1.0 1.0 36.0 41.6 27.0 23.0 5.0 4.0 4.0 24.0 13.0 17.0 12.9 1.1 1.0 0.4 0.2 2.0 1.3 6.2 3.1 33.2
% (all cases)
0.3 0.2 2.6 0.3 0.05 0.8 0.4 0.05 0.05
0.5 0.4 0.08 0.06
5.9 4.4 0.4 0.3 0.2 0.08
0.3 0.2
17.5
Recreational/adventure tourism activities determined from content analysis of &one-line' descriptions of accident circumstances provided in narrative "elds. Recreational/adventure tourism activities shown in italics.
hospital. Just 10 per cent of cases required more than 15 days hospitalisation. These "ndings were re#ected in the distribution of injury severity scale classi"cations (see Table 1), with just 17 per cent of cases classi"ed as &serious', and 1 per cent as &severe'. The majority of cases were classi"ed as &moderate' injuries (51 per cent). 3.2. The role of recreational/adventure activity in overseas visitor injury Approximately 15 per cent of overseas visitor injuries were sustained at a &place for recreation and sport', with other signi"cant injury locations being &street or highway' (13.5 per cent), &home' (7.1 per cent) and &public building' (4.4 per cent). In a large number of cases (n"2785, 47.5 per cent) the injury location was coded as
&unspeci"ed place'. It seems reasonable to assume, in the absence of any information from which injury location or activity could be determined, that 15 per cent of these unspeci"ed cases were recreational (i.e. the same proportion of cases are assumed to be recreational as observed for the total &known' cases). Based on this assumption, it is estimated that the actual proportion of overseas visitor injuries occurring in a &place for recreation and sport' is likely to be approximately 22 per cent. This suggests an overall sport and recreation injury-incidence rate of approximately 10 injuries per 100,000 overseas visitors. Sport and recreation injury-incidence rates were also calculated for each year of the analysis. No notable trends were observed in the annual incidence rates, which closely correlated with those for all overseas visitor injuries shown in Table 2.
T. Bentley et al. / Tourism Management 22 (2001) 373}381
Analysis by Event (determined from analysis of 3-digit event description E-codes and information extracted from narrative "elds) allowed for a more detailed identi"cation of the role of recreational/adventure activities in overseas visitor injury. Table 3 shows &event group' together with a breakdown of recreational activities within each event group. Recreational/adventure tourism activities are presented in italics. The largest event group category was falls (from a height and on the level), followed by motor vehicle tra$c accidents. The distribution of recreational/adventure tourism activities within &falls' and other non-tra$c event groups, suggests that these activities make a signi"cant contribution to hospital injury admissions among overseas visitors. The major recreational activities were skiing/snowboarding (n"364; 6.2 per cent of all injury cases), mountaineering/tramping (n"270; 4.6 per cent), horse riding (n"171; 2.9 per cent) and cycling (n"165; 2.8 per cent), although the proportion of cycle injuries sustained during organised cycle tours (rather than noncommercial/organised use) cannot be precisely determined from these data. Water-based activities included white water rafting (n"51; 0.8 per cent) and jet boating (n"21; 0.4 per cent), although the proportion of adventure tourism-related injuries involving &unspeci"ed boats/ships' cannot be determined. Aviation-related activities included parapenting/gliding (n"36; 0.9 per cent) and skydiving (n"23; 0.4 per cent). The incidence of scenic #ight injuries among helicopter and aircraft cases is unknown. The total contribution of recreational tourism activity to overseas visitor injuries for the period 1982}1996 comprised some 1027 events, representing 17.5 per cent of all overseas visitor injuries. It is likely that this total under-represents the true involvement of recreational activity in overseas visitor injury however, as an unknown proportion of unclassi"ed/unspeci"ed events (particularly &unspeci"ed' cycle, watercraft and aviation events in Table 2) may have been recreational/adventure tourism-related. Based on the assumption that 17 per cent of all such events were recreational/adventure tourism-related, an adjusted total of 1109 recreational events was obtained, representing approximately 19 per cent of overseas visitor injuries. This "gure suggests an overall recreational tourism injury-incidence rate of approximately 8.4 injuries per 100,000 overseas visitors. This contribution to overseas visitor morbidity is considerable, as demonstrated when weighed against that for motor vehicle tra$c accidents (12 injuries per 100,000 overseas visitors), an activity for which there is signi"cantly higher exposure amongst the tourist population. The event groups shown in Table 3 varied considerably in terms of injury severity. Length of hospital stay data suggested that the most serious injuries were sustained in motor vehicle tra$c accidents and aviation incidents. Some 25 per cent of injuries from these event
377
groups involved hospital stays of over 10 days, compared with between 5 and 10 per cent for the other event group categories. Shortest hospital stays were observed for cycle and horse-riding injuries. Injury severity score classi"cations generally supported these "ndings, with relatively high proportions of injuries classi"ed as &serious' or &severe' found for motor vehicle tra$c accidents (serious"32 per cent; severe"2.0 per cent) and aviationrelated injuries (serious"23 per cent; severe"2.5 per cent). Surprisingly, some 27 per cent of horse riding injuries were classi"ed as &serious', this "gure being at odds with the relatively short hospital stays of overseas visitors with horse riding-related injuries. 3.3. The spatial distribution of overseas visitor injuries The spatial distribution of overseas visitor injuries within New Zealand was determined indirectly from hospital codes (denoting the location of the hospital the injured person was admitted to). Table 4 shows the distribution of geographical region and major place of occurrence categories for each region. The region with the largest count of overseas visitor hospital admissions was Auckland (n"1358; 23 per cent), followed by Otago (n"934; 15.9 per cent), Canterbury (n"760; 13 per cent) and Rotorua (n"416; 7 per cent). These "gures re#ect the common pattern of travel by international tourists in New Zealand (Page & Thorn, 1997). The high proportion of Auckland hospital admissions is probably a re#ection of the fact that Auckland is the main gateway to New Zealand (Page & Hall, 1999), and the large numbers of overseas arrivals who stay with friends and relatives or undertake business trips in the Auckland area. Turning to the distribution of place of occurrence categories within these regional areas, it is notable that higher proportions of sport and recreation injuries occurred in those regions known to be the major centres for adventure tourism activity in New Zealand: Rotorua, Central North Island, Canterbury, Otago and Southland. In support of the role of recreational tourism in overseas visitor injury incidence, 8 per cent of all cases were admitted to hospitals in the Queenstown (Central Otago) area; Queenstown promotes itself as the capital of outdoor recreation and adventure tourism activity in New Zealand (Berno & Moore, 1996; Page & Hall, 1999). In order to consider the spatial distribution of speci"c activities, a simple correspondence analysis (Greenacre, 1984) was undertaken on event group and place of occurrence variables. Fig. 1 explains 77 per cent of the association between these variables, and indicates a number of regional &hot spots' for recreational/adventure tourism event groups. The association between the event group and place of occurrence variables can be identi"ed using the proximity of labels. Labels which are close together suggest associations between the corresponding categories.
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T. Bentley et al. / Tourism Management 22 (2001) 373}381
Table 4 Place of occurrence categories by geographic region Region
Total n
North Island Northland Auckland Waikato Bay of Plenty/Coromandel Eastland/Rotorua Central North Island Hawkes Bay Wairapapa/Wanganui/ New Plymouth Wellington South Island Marlborough/Abel Tasman West Coast Canterbury Otago Southland/Fiordland Other Total
%
Sport and recreation %
Road %
Home %
Public building %
Other %
400 1358 233 173 416 138 119 197
6.8 23.2 4.0 3.0 7.1 2.4 2.0 3.4
9.4 9.3 16.7 14.8 36.7 26.3 14.3 18.8
28.1 13.7 33.5 16.3 16.1 13.2 28.6 17.3
11.2 15.0 13.5 20.7 6.8 11.0 8.6 10.5
3.9 6.7 1.6 1.5 12.0 5.5 4.3 6.8
47.5 55.3 34.7 46.7 29.4 44.0 44.2 46.6
112
1.9
12.1
12.1
15.7
6.0
54.1
210 267 760 934 483 63
3.6 4.6 13.0 15.9 8.2 1.1
8.1 8.7 25.5 35.5 26.2 12.0
21.0 31.6 14.4 12.1 27.7 30.0
12.8 1.0 5.7 6.7 2.1 10.0
4.7 5.1 5.5 6.6 4.4 0.0
53.4 53.6 48.9 41.4 39.6 48.0
5863
100
Fig. 1. Correspondence analysis showing association between event group and place of occurrence.
Otago, Canterbury and Southland appear to be associated with slip, trip and fall accidents (many of which involved skiing, mountaineering or tramping), watercraft and aviation accidents, while pedal cycle injuries are most closely associated with Rotorua (home to several mountain biking routes), and horse riding (animal) injuries with Marlborough. No notable trends in the geographical distribution of overseas visitor injury over time were observed, except for a considerable increase in admissions to Otago hospitals compared to other regions for the six-year period, 1985}1990, when between 16 and 22 per cent of all injury cases were located in Otago.
3.3.1. The seasonal incidence of overseas visitor injury Almost one-half of injuries to overseas visitors occurred during the main summer months of December (11.7 per cent of cases), January (12.2 per cent), February (12.3 per cent) and March (11.2 per cent). Monthly injuryincidence rates (per 100,000 overseas visitors) were determined for the years 1989}1996. Highest injury rates were observed for the peak summer months, with injury rates of at least "ve per 100,000 overseas visitors for January}March. Interestingly, injury-incidence rates were signi"cantly lower for the month of December (3.6). A second peak in injury-incidence rates was observed for the winter months, July (4), August (4.5) and September
T. Bentley et al. / Tourism Management 22 (2001) 373}381
379
Table 5 Age group by gender of injured overseas visitor Age group (year)
Total (%)
Male (%)
Female (%)
0}9 10}19 20}29 30}39 40}49 50}59 60# Total
7.0 10.3 29.4 14.9 9.6 9.2 19.8 100
58.0 64.1 61.5 65.6 60.0 45.0 31.9 54.6
42.0 35.9 38.5 34.4 40.0 55.0 68.1 45.4
Fig. 2. Major place of occurrence categories by month of injury.
(4). Lowest overseas injury-incidence rates were observed for May, October and November (all 3.1). Further analysis considered the relationship between the month in which the injury occurred and the place of injury occurrence. Fig. 2 shows the distribution of major place of occurrence categories for each month. Sport and recreation injuries increased sharply over the winter sports season (July}September), peaking at over 22 per cent of all injuries in August. It is interesting to note the inverse relationship between sport and recreational injuries and those sustained on the road and at home, with a marked increase in home and road accidents during peak visitor periods: December through February. Further analysis highlighted the role of winter sports in overseas visitor injury incidence, with highest counts of winter injuries found for the major skiing/mountain recreation locations. These were Central North Island, Canterbury, Otago and Southland/Fiordland, while other tourist destinations (e.g. Auckland and Rotorua) had highest injury incidence during the summer months. 3.4. The incidence of injury in overseas visitor population groups The highest incidence of injury was found for overseas visitors in the 20}30 years age range (29 per cent of all hospital admissions), while about one-"fth of all overseas visitor injuries were experienced by those aged 60 years and over. Table 5 shows the distribution of cases by age group and gender of injured person. A marked relationship between age and gender is evident, with young and middle-aged males and older female overseas visitors sustaining higher proportions of injuries. The greater incidence of injuries among younger male visitors can probably be explained by greater male participation in recreational and sporting activities. Indeed, further anal-
Fig. 3. Major place of occurrence categories by age group.
ysis revealed that 25 per cent of injuries to males occurred in a &place for recreation and sport', compared to just 15 per cent of female injuries. Fig. 3 shows the distribution of injuries for the major place of occurrence categories by age group. Peaks in sport and recreation injuries (40 per cent of sport and recreation injuries) and road injuries (30 per cent of road injuries) were observed for overseas visitors in the 20}29 years age group. By contrast, elderly visitors more commonly experienced injuries in the home. The distribution of event groups by gender suggests a clear delineation between the types of adventure tourism-related activities male and female overseas visitors were undertaking at the time of their injury. Females, for example, were considerably over-represented amongst horse riding accidents, contributing some 72 per cent of injuries resulting from falls from horses. Male overseas visitors, on the other hand, were over-represented in cycle (65 per cent of all cycle injuries); watercraft (70 per cent); aviation (64 per cent) and struck by/strike against events (many of which were contact sports injuries) (72 per cent). These "ndings, together with those for age distribution reported above, suggest the most appropriate targets for safety communications and other
380
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measures to reduce the incidence of speci"c adventure tourism and recreational injuries.
4. Discussion Recreational and adventure tourism injuries made a signi"cant contribution to overseas visitor morbidity over the 15-year period up to December 1996, with one in every 12,000 visitors to New Zealand (8.4 injuries per 100,000 arrivals) being admitted to hospital following a recreational/adventure tourism-related incident. It can be argued that this "gure is unacceptable given the relatively low exposure of tourists to recreational tourism activities in comparison to road travel, an activity for which approximately 1 in every 8300 overseas visitors was injured during the same period (12 injuries per 100,000 arrivals). Skiing, mountaineering and tramping together comprised 10 per cent of all overseas visitor injuries. It is noted these activities most commonly involve independent adventure activity, rather than organised commercial/guided adventure tourism. These "ndings are in-line with those reported for mountain recreation fatalities (Johnston, 1989; Bentley et al., 2000), and suggest that the independent adventurer should be the major target for safety communications and other interventions to reduce injury risk amongst overseas visitors to New Zealand and other countries. Such information should target high-risk travellers (i.e. travellers in the 18}35 age range), and should contain messages about the risks of travelling alone or without a guide, the level of experience and skill required to participate safely, and the fast-changing nature of New Zealand's mountain and marine environmental conditions. There are a number of opportunities to present safety information regarding potentially hazardous recreational pursuits to targeted travellers. These include: at country of origin medical centres (often visited for pre-travel vaccination); at airports and in in-#ight entertainment and information literature; at destination visitor centres, accommodation and travel o$ces (i.e. backpacker establishments, overnight huts and ski lodges); and at the point at which activities are provided or commenced. Other activities making notable contributions to tourist injury morbidity included horse riding (2.6 per cent of all injuries) and cycling (2.8 per cent of all injuries), although the proportion of cycle accidents involved organised cycle tours or mountain biking activities is unknown. White water rafting, jet boating and kayaking together contributed just 1.2 per cent of all overseas visitor injuries, this "gure being somewhat surprising given government "gures which suggest that between 100,000 and 200,000 overseas visitors participate in these water-based activities annually (New Zealand Tourism Board, 1993).
The "ndings of this research support those of previous studies considering adventure tourism safety in New Zealand (Bentley et al., 2000), indicating that activities for which there is a lower &perceived risk' but a relatively high &actual risk' (e.g. horse riding and cycle tours) should be the focus of industry attention to improve the standards of safety for participants. The best means of achieving higher standards of safety in these sectors is to introduce regulatory codes of practice, detailing issues such as level of training, quali"cations and experience required for guides, appropriate client}guide ratios, equipment speci"cations and the use of personal protective equipment. While industry-led voluntary codes of practice for these and other adventure tourism activity sectors have recently been put in place, these data indicate the need to revisit the issue of regulation versus industry self-regulation in the New Zealand adventure tourism industry (Ministry of Commerce, 1996; Page & Meyer, 1996). There is also considerable scope for adventure tourism operators and providers of recreational activities to take action to raise the standard of client safety. Operators should ascertain whether their clients have su$cient knowledge, experience, "tness levels and understanding of potential dangers, before allowing participation in their activity. Communicating safety instructions may be particularly problematic due to language and cultural di$culties. The challenge for operators is to ensure all key safety information is fully understood by participants in their activity, as it may be too late to relay safety instructions to a client once the activity is underway. Further measures that operators of adventure and recreational activities can take to improve client safety include careful choice of route and terrain to minimise the risk of slip, trip and fall injuries (the most common accident type in adventure pursuits, Bentley et al., 2000), and ensuring all participants are provided with footwear and clothing appropriate for prevailing underfoot and weather conditions. The application of operational risk management (McKay, 1998) to adventure activities should ensure all risks are identi"ed, assessed and, where potential for injury exists, removed or ameliorated. The study methodology is subject to a number of limitations, the most important of which is that the data on which it relies (NZHIS mobidity data) represent only those injuries resulting in visits to New Zealand public hospitals. The extent of unreported injuries, or injuries that resulted in treatment in the injured person's country of origin, is unknown. Furthermore, it is likely that certain visitor groups will be less likely to report injuries than others, notably the young and other &budget' travellers who are less likely to carry travel insurance and hence less inclined to visit a New Zealand hospital. Despite this potential source of bias in the "ndings reported here, tourists most likely to fall within the &budget traveller' age group (i.e. 20}30 years) are over-represented in
T. Bentley et al. / Tourism Management 22 (2001) 373}381
sport and recreation injury statistics, suggesting further evidence for this being a high-risk population. The unavailability of data for overseas visitor morbidity for the period 1997 to date is regrettable. In particular, the absence of data for this period impacts on our inability to determine whether patterns and trends in injury incidence mirror the rapid growth in certain sectors of the New Zealand adventure tourism industry over recent years. It should be noted, however, that New Zealand is unique in having a national morbidity data collection system, albeit somewhat slow in its ability to provide annual clean data sets to researchers. Further research is to investigate the injury experience of a large sample of overseas visitors to New Zealand. As well as providing support for this and previous work on adventure tourism safety, the "ndings should provide comprehensive data on the causes of injury among overseas visitors. This research, together with other work focusing on di!erent aspects of tourist safety in New Zealand, should help us better understand the health and safety needs of overseas visitors to New Zealand, and how intervention strategies can most e!ectively impact on tourist safety.
Acknowledgements Research costs associated with this research were funded by a Massey University College of Business Research Grant. The Injury Prevention Research Unit is funded jointly by the ACC and Health Research Council of New Zealand. The authors are grateful to the New Zealand Health Information Service for providing the hospital discharge data used in this study. The views and opinions expressed in this paper are those of the authors and do not necessarily re#ect those of the above organisations.
References Bentley, T., Page, S., & Laird, I. (2000). Safety in New Zealand's adventure tourism industry: The client injury experience of adventure tourism operators. Journal of Travel Medicine, 7, 239}246. Berno, T., & Moore, K. (1996). The nature of the adventure tourism experience in Queenstown. Paper presented at the Tourism Down Under Conference, Centre for Tourism, University of Otago, December 1996. Bovet, S. (1994). Safety concerns world travel market: B-M survey shows. Public Relations Review, 50, 8. Cossar, J., Reid, D., Fallon, R., Bell, E., Riding, M., Follett, E., Dow, B., Mitchell, S., & Grist, N. (1990). A cumulative review of studies on travellers, their experiences of illness and the implications of these "ndings. Journal of Infection, 21, 27}42. Greenacre, M. (1984). Theory and application of correspondence analysis. London: Academic Press Inc.
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Greenaway, R. (1996). Thrilling not killing: Managing the risk tourism business. Management, 46}49. Guptill, K., Hargarten, S., & Baker, T. (1991). American travel deaths in Mexico: Causes and prevention strategies. West Journal of Medicine, 154, 169}171. Hall, C., & McArthur, S. (1991). Commercial white water rafting in Australia. Australian Journal of Leisure and Recreation, 1, 25}30. Hargarten, W., Baker, M., & Guptill, K. (1991). Overseas fatalities of United States citizen travelers: An analysis of deaths related to international travel. Annals of Emergency Medicine, 20(6), 622}626. Hartung, G., Goebert, D., Taniguchi, R., & Okamoto, G. (1990). Epidemiology of ocean sports-related injuries in Hawaii: &Akahele O Ke Kai'. Hawaii Medical Journal, 49, 52}56. Johnston, M. (1989). Accidents in mountain recreation: The experiences of international and domestic visitors in New Zealand. GeoJournal, 19, 323}328. Major, R. (1995). Making sense of Cave Creek. New Zealand Leisure Manager, 21}22. McKay, D. (1998). Don't run the risk. New Zealand Local Government, 39}41. McLaughlan, M. (1995). White water death: Why is the Shotover New Zealand's most lethal river? North and South, 70}81. Ministry of Commerce. (1996). Safety management in the adventure tourism industry: Voluntary and regulatory approaches. Wellington: Ministry of Commerce. New Zealand Tourism Board. (1993). New Zealand international visitor survey 1992/3. Wellington: New Zealand Tourism Board. Nichol, J., Wilks, J., & Wood, M. (1996). Tourists as inpatients in Queensland regional hospitals. Australian Health Review, 19, 55}72. Page, S., & Hall, C. (1999). New Zealand international tourism reports, 4, 44}66. Page, S., & Meyer, D. (1996). Tourist accidents: An exploratory analysis. Annals of Tourism Research, 23, 666}690. Page, S., & Meyer, D. (1997). Injuries and accidents among international tourists in Australasia. In S. Clift, & P. Grabowski (Eds.), Health and tourism (pp. 61}80). London: Cassell. Page, S., & Thorn, K. (1997). Towards sustainable tourism planning in New Zealand: Public sector planning responses. Journal of Sustainable Tourism, 5, 59}77. Paixao, M., Dewar, R., Cossar, J., & Reid, D. (1991). What do Scots die of when abroad? Scottish Medical Journal, 36, 114}116. Philipp, R., & Hodgkinson, G. (1994). The management of health and safety hazards in tourist resorts. International Journal of Occupational Medicine and Environmental Health, 7, 207}219. Ryan, C., Robertson, E., & Page, S. (1996). New Zealand students: Risk behaviours while on holiday. Tourism Management, 17, 64}69. Wilks, J. (1999). International tourists, motor vehicles and road safety: A review of the literature leading up to the Sydney 2000 Olympics. Journal of Travel Medicine, 6, 115}121. Wilks, J., & Atherton, T. (1994). Health and safety in marine tourism: A social, medical and legal appraisal. Journal of Tourism Studies, 5, 2}16. Wilks, J., & Oldenburg, B. (1995). Tourist health: The silent factor in customer service. Australian Journal of Hospitality Management, 2, 13}23. Wilks, J., Pendergast, D., & Service, M. (1996). Newspaper reporting of tourist health and safety issues. Australian Leisure, 7, 45}48. Wilks, J., & Watson, B. (1998). Road safety and international visitors in Australia: Looking beyond the tip of the iceberg. Travel Medicine International, 16, 194}198. Wilks, J., Watson, B., & Faulks, I. (1999). International tourists and road safety in Australia: Developing a national research and management programme. Tourism Management, 20, 645}654. World Tourism Organisation. (1996). Tourist safety. Madrid: World Tourism Organisation.
Recreational tourism injuries among visitors to New Zealand: an exploratory analysis using hospital discharge data Tim Bentley , Denny Meyer, Stephen Page *, David Chalmers Centre for Occupational Human Factors Ergonomics, Forest Research, Sala Street, Private Bag 3020, Rotorua, New Zealand Department of Statistics, Massey University-Albany, Private Bag 102 904, Auckland, New Zealand Department of Marketing, University of Stirling, Stirling, Scotland FK9 4LA, UK Injury Prevention Research Unit, Department of Preventive and Social Medicine, University of Otago, PO Box 913, Dunedin, New Zealand Received 8 November 1999; accepted 26 May 2000
Abstract New Zealand Health Information Service (NZHIS) morbidity data for the 15-year period, 1982}1996, were analysed to determine the role of recreational and adventure tourism in overseas visitor injuries, and identify recreational activities with greatest injury occurrence. Approximately 19 per cent of all injuries involved recreational/adventure tourism activities, corresponding to 8.4 injuries per 100,000 overseas visitor arrivals. This "gure can be compared to that for motor vehicle tra$c accidents (12), and suggests a signi"cant recreational tourism injury problem in New Zealand. Injuries were concentrated in regions known to be major centres for adventure tourism in New Zealand, and were most commonly sustained by overseas visitors aged between 20 and 40 years. Tourist injuries were observed most frequently for activities that involve independent, unguided recreation, notably skiing, mountaineering and tramping. Of the commercial adventure tourism activities, horse riding and cycling were the only signi"cant contributors to overseas visitor injuries. 2001 Elsevier Science Ltd. All rights reserved. Keywords: Adventure tourism; Recreational tourism; Tourist safety
1. Introduction The health needs of international tourists place a considerable burden on the health and safety services of tourism destinations (Wilks & Oldenburg, 1995; Nichol, Wilks, & Wood, 1996). As destinations such as Australia and New Zealand experience considerable growth in their tourism markets, there is an increasing need to understand the health and safety needs of overseas tourists. Central to achieving this understanding is the identi"cation of health and safety problems most frequently experienced by overseas visitors (Wilks & Atherton, 1994; Bentley, Page, & Laird, 2000). International research has consistently recognised unintentional injury as a leading cause of tourist morbidity and mortality (Hartung, Goebert, Taniguchi, & Okamoto, 1990; Guptill, Hargarten, & Baker, 1991;
* Corresponding author. Tel.: #44-1786-466451; fax: #44-1786464745. E-mail address: [email protected] (S. Page).
Hargarten, Baker, & Guptill, 1991; Paixao, Dewar, Cossar, & Reid, 1991; Nichol et al., 1996; Page & Meyer, 1996, 1997; Wilks, 1999). Moreover, tourists appear more likely to be injured or killed as a result of incidents while overseas than when in their country of residence (Hargarten et al., 1991), and international visitors require hospitalisation due to injury more commonly than interstate visitors or local residents (Nichol et al., 1996). Despite these "ndings, the tourist safety literature is very limited. It does, however, o!er a number of explanations for this increased injury risk amongst overseas travellers. These can be broadly grouped into the following factors: E exposure to unfamiliar road, marine, mountain, wilderness and built environments (Johnston, 1989; Guptill et al., 1991; Philipp & Hodgkinson, 1994; Wilks & Atherton, 1994; Wilks & Watson, 1998); E increased time spent engaged in activities for which there is a risk of injury, particularly driving (Wilks, Watson, & Faulks, 1999); E exposure to unfamiliar activities such as driving on the other side of the road (Guptill et al., 1991; Page
0261-5177/01/$ - see front matter 2001 Elsevier Science Ltd. All rights reserved. PII: S 0 2 6 1 - 5 1 7 7 ( 0 0 ) 0 0 0 6 3 - 7
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& Meyer, 1996; Wilks et al., 1999), marine tourism (Wilks & Atherton, 1994) and adventure tourism (Page & Meyer, 1996, 1997; Bentley et al., 2000); E relaxed attitudes towards risk and reduced inhibitions among holiday-makers (Cossar et al., 1990; Philipp & Hodgkinson, 1994; Ryan, Robertson, & Page, 1996). Tourist accidents can have a profound e!ect on the image of a country's tourism industry, and the selection of tourist destinations by potential holiday-makers (Bovet, 1994; Wilks, Pendergast, & Service, 1996; World Tourism Organisation, 1996). Nowhere is this better illustrated than in the adventure tourism industry, for which major negative events, such as the 1999 canyoning incident in Switzerland, can have signi"cant long-term social and economic impacts on the industry and communities whose economies are dependent upon tourism. Adventure tourism is a rapidly expanding sector of the New Zealand tourism industry (Berno & Moore, 1996), and an increasing number of visitors seek adventure activity during their stay in New Zealand (Major, 1995). There is growing evidence that adventure and recreational injuries make a signi"cant contribution to overseas visitor morbidity and mortality in New Zealand (Bentley et al., 2000; Page & Meyer, 1996, 1997). Moreover, some New Zealand adventure activities, notably white water rafting, scenic #ights and mountain recreation, appear to present signi"cant risks of serious and fatal injury to clients (Johnston, 1989; Hall & McArthur, 1991; McLaughlan, 1995; Greenaway, 1996). Recent research by the present authors, however, has suggested that it is adventure activities with lower levels of &perceived risk' associated with them which may have highest &actual' injury risk, when all levels of injury severity are considered. Some 142 New Zealand adventure tourism operators, representing 21 di!erent activity sectors, were asked by postal questionnaire to document the number of minor and serious injuries experienced by clients of their activity during the previous 12-month period. Using activity exposure data supplied by operators (duration of activity and travel to and from activity location), client injury-incidence rates were determined for each activity sector. Highest client injury-incidence rates were found for cycle touring, quad biking, horse riding and caving (Bentley et al., 2000). The authors note that operators reporting the highest incidence of injuries o!ered activities which involved the risk of falling from a height whilst in motion. Furthermore, activities with highest reported incidence of injury came from sectors which did not have a high level of perceived risk associated with them, did not come under the jurisdiction of any government authority, and were not the subject of any regulatory code of practice. The present study builds on this work, considering the role of recreational and adventure tourism in public hospital injury admissions for non-New Zealand resi-
dents (overseas visitors to New Zealand) over a 15-year period: 1982}1996. The aims of the study were to quantify the role of recreational activities in overseas visitor hospital admissions, to compare recreational tourism with motor vehicle tra$c accidents as a major cause of overseas visitor morbidity, and to identify recreational activities for which highest frequencies of injuries were sustained.
2. Method The data source used was the Ministry of Health's New Zealand Health Information Service (NZHIS) public hospital morbidity data "les, routinely collated on all discharges from public hospitals. The data set contained information about all non-resident discharges from public hospitals throughout New Zealand, for the period 1982}1996. The large majority of cases included in the analysis were tourist injuries, with a small but unknown proportion of cases involving non-residents working o!shore (mostly "shing and other vessel crew), and persons working in New Zealand on overseas visitor work permits. Table 1 gives details of variables considered in the analysis, together with an explanation of how each variable was derived from the data set, and whether variables had missing cases (variables were only considered where data were available for more than 50 per cent of cases). The circumstances of injuries were coded according to the International Classi"cation of Diseases: External Causes of Injury and Poisoning (Commission on Professional and Hospital Activities). The numerous 3-digit E-code values found within the data set were collapsed into 17 event groups, providing a variable more suitable for analysis. For example, the event group &falls from a height' and &falls on the level' was derived from E-codes 880}888, and included E-codes denoting &fall on or from stairs or steps', &fall into hole or other opening in surface', and &fall from one level to another' and &fall on the same level from slipping, tripping, or stumbling'. Recreational tourism activities were identi"ed from content analysis of the &one-line' event descriptions. Thus, for relevant event group categories (i.e. motor vehicle non-tra$c accidents; cycles; animals; watercraft; aviation; falls from a height and on the level; struck by/strike against object or person), the &one-line' descriptions of accident circumstances were examined to determine the involvement of recreational activities. Where insu$cient information was contained in the &one-line' event descriptions, cases were recorded as &unspeci"ed' (e.g. &unspeci"ed boat/ship'; &unspeci"ed aircraft' as detailed later in Table 3). The geographical location of overseas visitor injuries within New Zealand had to be determined indirectly from information on the hospital to which the injured
T. Bentley et al. / Tourism Management 22 (2001) 373}381
375
Table 1 Variables considered in the analysis of overseas visitor injuries Variables considered in the analysis
Where data were derived
Example of variable
Missing cases
Place of occurrence
Location code
Yes
Event
First 3 digits of E-code
Recreational/adventure tourism activity
Event description (&one-line' description of injury circumstances provided in narrative "elds) Number of days stay in hospital Injury severity score code
Farm, road, place for sport or recreation, home Motor vehicle tra$c accident, watercraft, fall on the level, animal &hang glider blown to ground'; &fell while skiing'; &thrown from a horse' 2 days 1"minor, 2"moderate, 3"serious, 4"severe Hospital number (e.g. Dunedin, Christchurch) 1982}1996 January Precise age of injured visitor Male
No Yes
Hospital days Injury severity score Geographical region
Hosptial code of hospital injured visitor was admitted to Year of discharge Month of injury Age Gender of injured visitor
Year of injury Month of injury Age group Gender
Table 2 Overseas visitor injury incidence: 1982}1996 Year
Overseas visitor arrivals (;10)
Hospital admissions n
1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 Total
472.6 487.7 518.4 570.0 689.1 763.2 855.5 867.5 993.4 967.1 999.7 1086.6 1213.3 1343.0 1441.8
173 245 243 291 304 379 310 383 444 423 492 589 606 454 527
13,268.9
5863
Injury-incidence rate
% 3.0 4.2 4.1 5.0 5.2 6.5 5.3 6.5 7.6 7.2 8.4 10.0 10.3 7.7 9.0 100
37 50 47 51 44 50 36 44 45 44 49 54 50 34 37
No No
No No Yes No No
Data on the nationality of injured overseas visitors were insu$ciently complete to undertake a worthwhile analysis, this being a major limitation of the study. Data were prepared for analysis as described above, and descriptive analysis of the data set was undertaken using SAS Version 6.12. Crosstabular analysis and correspondence analysis (Greenacre, 1984) were applied as appropriate to the variables described in Table 1. Correspondence analysis is a multidimentional scaling method for spatially portraying categorical data, originally expressed as crosstabulations. Row and column labels are represented as points in a joint space in which interpoint distances can be related to the row}column association (Greenacre, 1984).
3. Results 3.1. Incidence of overseas visitor hospital admissions: 1982}1996
44
Source: Statistics New Zealand. Injuries per 100,000 arrivals.
person was admitted. The many hospital codes found in the data set were collapsed into 16 regional groups to allow for a manageable analysis of the spatial distribution of injury events. This method of identifying event location will have produced a small but unknown degree of error, as patients may, in some cases, have been transferred to hospitals in other regions, or may have been admitted to hospital later in their holiday as the extent of their injury became apparent. Nevertheless, it is reasonable to assume that the location of the incident would, in most cases, correspond to the hospital of admission.
Some 5863 overseas visitors were admitted to New Zealand public hospitals as a result of injury during the 14-year period, 1982}1996. Injury-incidence rates (per 100,000 overseas visitor arrivals) were calculated for each year, 1982}1996, and are shown in Table 2. No notable trends across time were observed for overseas visitor hospital admissions, although data for 1995 and 1996 suggest that injury rates may be falling. The overall incidence rate of 44 injuries per 100,000 overseas visitor arrivals indicates that approximately one in every 2300 overseas visitors was admitted to hospital with an injury during their stay in New Zealand. Many of these cases did not involve serious injuries, however. Indeed, one-half of visitors were hospitalised for a period of two days or less, while 80 per cent spent less than 10 days in
376
T. Bentley et al. / Tourism Management 22 (2001) 373}381
Table 3 The role of recreational and adventure tourism in overseas visitor injury morbidity: 1982}1996 Event group
n
Motor vehicle tra$c Motor vehicle non-tra$c Pedal cycle
1604 59 165
%
27.4 1.0 2.8
Animal-related
174
3.0
Watercraft-related
320
5.5
Aviation-related
100
1.7
Falls from a height/falls on the same level
2027
34.6
Struck by/strike against object or person
325
5.5
Other (non-recreational events)
1089
18.6
Total
5863
100
Recreational/adventure tourism activities
Quad/farm bikes Road cycling Mountain biking Other/unclassi"ed Horse (fell from) Horse (kicked by) Bull (rodeo) White water raft Jet boat Kayak/canoe Diving Crew/"shing boat Unspeci"ed boat/ship Parapenting/gliding Skydiving Glider/unpowered Hang glider Crew/work-related Unspeci"ed aircraft Helicopter Skiing/snowboarding Mountaineering/tramping Luge Flying fox Parapenting White water rafting Playground activity Swimming pool/spa Skiing/snowboarding Mountaineering/tramping Rugby/other sports
Total estimated adventure tourism
n
%
18 95 13 57 153 18 3 46 21 3 3 115 132 27 23 5 4 4 24 13 344 260 24 18 9 5 40 27 20 10 108
1027
30.5 57.6 7.9 34.5 87.9 10.3 1.8 14.5 6.6 1.0 1.0 36.0 41.6 27.0 23.0 5.0 4.0 4.0 24.0 13.0 17.0 12.9 1.1 1.0 0.4 0.2 2.0 1.3 6.2 3.1 33.2
% (all cases)
0.3 0.2 2.6 0.3 0.05 0.8 0.4 0.05 0.05
0.5 0.4 0.08 0.06
5.9 4.4 0.4 0.3 0.2 0.08
0.3 0.2
17.5
Recreational/adventure tourism activities determined from content analysis of &one-line' descriptions of accident circumstances provided in narrative "elds. Recreational/adventure tourism activities shown in italics.
hospital. Just 10 per cent of cases required more than 15 days hospitalisation. These "ndings were re#ected in the distribution of injury severity scale classi"cations (see Table 1), with just 17 per cent of cases classi"ed as &serious', and 1 per cent as &severe'. The majority of cases were classi"ed as &moderate' injuries (51 per cent). 3.2. The role of recreational/adventure activity in overseas visitor injury Approximately 15 per cent of overseas visitor injuries were sustained at a &place for recreation and sport', with other signi"cant injury locations being &street or highway' (13.5 per cent), &home' (7.1 per cent) and &public building' (4.4 per cent). In a large number of cases (n"2785, 47.5 per cent) the injury location was coded as
&unspeci"ed place'. It seems reasonable to assume, in the absence of any information from which injury location or activity could be determined, that 15 per cent of these unspeci"ed cases were recreational (i.e. the same proportion of cases are assumed to be recreational as observed for the total &known' cases). Based on this assumption, it is estimated that the actual proportion of overseas visitor injuries occurring in a &place for recreation and sport' is likely to be approximately 22 per cent. This suggests an overall sport and recreation injury-incidence rate of approximately 10 injuries per 100,000 overseas visitors. Sport and recreation injury-incidence rates were also calculated for each year of the analysis. No notable trends were observed in the annual incidence rates, which closely correlated with those for all overseas visitor injuries shown in Table 2.
T. Bentley et al. / Tourism Management 22 (2001) 373}381
Analysis by Event (determined from analysis of 3-digit event description E-codes and information extracted from narrative "elds) allowed for a more detailed identi"cation of the role of recreational/adventure activities in overseas visitor injury. Table 3 shows &event group' together with a breakdown of recreational activities within each event group. Recreational/adventure tourism activities are presented in italics. The largest event group category was falls (from a height and on the level), followed by motor vehicle tra$c accidents. The distribution of recreational/adventure tourism activities within &falls' and other non-tra$c event groups, suggests that these activities make a signi"cant contribution to hospital injury admissions among overseas visitors. The major recreational activities were skiing/snowboarding (n"364; 6.2 per cent of all injury cases), mountaineering/tramping (n"270; 4.6 per cent), horse riding (n"171; 2.9 per cent) and cycling (n"165; 2.8 per cent), although the proportion of cycle injuries sustained during organised cycle tours (rather than noncommercial/organised use) cannot be precisely determined from these data. Water-based activities included white water rafting (n"51; 0.8 per cent) and jet boating (n"21; 0.4 per cent), although the proportion of adventure tourism-related injuries involving &unspeci"ed boats/ships' cannot be determined. Aviation-related activities included parapenting/gliding (n"36; 0.9 per cent) and skydiving (n"23; 0.4 per cent). The incidence of scenic #ight injuries among helicopter and aircraft cases is unknown. The total contribution of recreational tourism activity to overseas visitor injuries for the period 1982}1996 comprised some 1027 events, representing 17.5 per cent of all overseas visitor injuries. It is likely that this total under-represents the true involvement of recreational activity in overseas visitor injury however, as an unknown proportion of unclassi"ed/unspeci"ed events (particularly &unspeci"ed' cycle, watercraft and aviation events in Table 2) may have been recreational/adventure tourism-related. Based on the assumption that 17 per cent of all such events were recreational/adventure tourism-related, an adjusted total of 1109 recreational events was obtained, representing approximately 19 per cent of overseas visitor injuries. This "gure suggests an overall recreational tourism injury-incidence rate of approximately 8.4 injuries per 100,000 overseas visitors. This contribution to overseas visitor morbidity is considerable, as demonstrated when weighed against that for motor vehicle tra$c accidents (12 injuries per 100,000 overseas visitors), an activity for which there is signi"cantly higher exposure amongst the tourist population. The event groups shown in Table 3 varied considerably in terms of injury severity. Length of hospital stay data suggested that the most serious injuries were sustained in motor vehicle tra$c accidents and aviation incidents. Some 25 per cent of injuries from these event
377
groups involved hospital stays of over 10 days, compared with between 5 and 10 per cent for the other event group categories. Shortest hospital stays were observed for cycle and horse-riding injuries. Injury severity score classi"cations generally supported these "ndings, with relatively high proportions of injuries classi"ed as &serious' or &severe' found for motor vehicle tra$c accidents (serious"32 per cent; severe"2.0 per cent) and aviationrelated injuries (serious"23 per cent; severe"2.5 per cent). Surprisingly, some 27 per cent of horse riding injuries were classi"ed as &serious', this "gure being at odds with the relatively short hospital stays of overseas visitors with horse riding-related injuries. 3.3. The spatial distribution of overseas visitor injuries The spatial distribution of overseas visitor injuries within New Zealand was determined indirectly from hospital codes (denoting the location of the hospital the injured person was admitted to). Table 4 shows the distribution of geographical region and major place of occurrence categories for each region. The region with the largest count of overseas visitor hospital admissions was Auckland (n"1358; 23 per cent), followed by Otago (n"934; 15.9 per cent), Canterbury (n"760; 13 per cent) and Rotorua (n"416; 7 per cent). These "gures re#ect the common pattern of travel by international tourists in New Zealand (Page & Thorn, 1997). The high proportion of Auckland hospital admissions is probably a re#ection of the fact that Auckland is the main gateway to New Zealand (Page & Hall, 1999), and the large numbers of overseas arrivals who stay with friends and relatives or undertake business trips in the Auckland area. Turning to the distribution of place of occurrence categories within these regional areas, it is notable that higher proportions of sport and recreation injuries occurred in those regions known to be the major centres for adventure tourism activity in New Zealand: Rotorua, Central North Island, Canterbury, Otago and Southland. In support of the role of recreational tourism in overseas visitor injury incidence, 8 per cent of all cases were admitted to hospitals in the Queenstown (Central Otago) area; Queenstown promotes itself as the capital of outdoor recreation and adventure tourism activity in New Zealand (Berno & Moore, 1996; Page & Hall, 1999). In order to consider the spatial distribution of speci"c activities, a simple correspondence analysis (Greenacre, 1984) was undertaken on event group and place of occurrence variables. Fig. 1 explains 77 per cent of the association between these variables, and indicates a number of regional &hot spots' for recreational/adventure tourism event groups. The association between the event group and place of occurrence variables can be identi"ed using the proximity of labels. Labels which are close together suggest associations between the corresponding categories.
378
T. Bentley et al. / Tourism Management 22 (2001) 373}381
Table 4 Place of occurrence categories by geographic region Region
Total n
North Island Northland Auckland Waikato Bay of Plenty/Coromandel Eastland/Rotorua Central North Island Hawkes Bay Wairapapa/Wanganui/ New Plymouth Wellington South Island Marlborough/Abel Tasman West Coast Canterbury Otago Southland/Fiordland Other Total
%
Sport and recreation %
Road %
Home %
Public building %
Other %
400 1358 233 173 416 138 119 197
6.8 23.2 4.0 3.0 7.1 2.4 2.0 3.4
9.4 9.3 16.7 14.8 36.7 26.3 14.3 18.8
28.1 13.7 33.5 16.3 16.1 13.2 28.6 17.3
11.2 15.0 13.5 20.7 6.8 11.0 8.6 10.5
3.9 6.7 1.6 1.5 12.0 5.5 4.3 6.8
47.5 55.3 34.7 46.7 29.4 44.0 44.2 46.6
112
1.9
12.1
12.1
15.7
6.0
54.1
210 267 760 934 483 63
3.6 4.6 13.0 15.9 8.2 1.1
8.1 8.7 25.5 35.5 26.2 12.0
21.0 31.6 14.4 12.1 27.7 30.0
12.8 1.0 5.7 6.7 2.1 10.0
4.7 5.1 5.5 6.6 4.4 0.0
53.4 53.6 48.9 41.4 39.6 48.0
5863
100
Fig. 1. Correspondence analysis showing association between event group and place of occurrence.
Otago, Canterbury and Southland appear to be associated with slip, trip and fall accidents (many of which involved skiing, mountaineering or tramping), watercraft and aviation accidents, while pedal cycle injuries are most closely associated with Rotorua (home to several mountain biking routes), and horse riding (animal) injuries with Marlborough. No notable trends in the geographical distribution of overseas visitor injury over time were observed, except for a considerable increase in admissions to Otago hospitals compared to other regions for the six-year period, 1985}1990, when between 16 and 22 per cent of all injury cases were located in Otago.
3.3.1. The seasonal incidence of overseas visitor injury Almost one-half of injuries to overseas visitors occurred during the main summer months of December (11.7 per cent of cases), January (12.2 per cent), February (12.3 per cent) and March (11.2 per cent). Monthly injuryincidence rates (per 100,000 overseas visitors) were determined for the years 1989}1996. Highest injury rates were observed for the peak summer months, with injury rates of at least "ve per 100,000 overseas visitors for January}March. Interestingly, injury-incidence rates were signi"cantly lower for the month of December (3.6). A second peak in injury-incidence rates was observed for the winter months, July (4), August (4.5) and September
T. Bentley et al. / Tourism Management 22 (2001) 373}381
379
Table 5 Age group by gender of injured overseas visitor Age group (year)
Total (%)
Male (%)
Female (%)
0}9 10}19 20}29 30}39 40}49 50}59 60# Total
7.0 10.3 29.4 14.9 9.6 9.2 19.8 100
58.0 64.1 61.5 65.6 60.0 45.0 31.9 54.6
42.0 35.9 38.5 34.4 40.0 55.0 68.1 45.4
Fig. 2. Major place of occurrence categories by month of injury.
(4). Lowest overseas injury-incidence rates were observed for May, October and November (all 3.1). Further analysis considered the relationship between the month in which the injury occurred and the place of injury occurrence. Fig. 2 shows the distribution of major place of occurrence categories for each month. Sport and recreation injuries increased sharply over the winter sports season (July}September), peaking at over 22 per cent of all injuries in August. It is interesting to note the inverse relationship between sport and recreational injuries and those sustained on the road and at home, with a marked increase in home and road accidents during peak visitor periods: December through February. Further analysis highlighted the role of winter sports in overseas visitor injury incidence, with highest counts of winter injuries found for the major skiing/mountain recreation locations. These were Central North Island, Canterbury, Otago and Southland/Fiordland, while other tourist destinations (e.g. Auckland and Rotorua) had highest injury incidence during the summer months. 3.4. The incidence of injury in overseas visitor population groups The highest incidence of injury was found for overseas visitors in the 20}30 years age range (29 per cent of all hospital admissions), while about one-"fth of all overseas visitor injuries were experienced by those aged 60 years and over. Table 5 shows the distribution of cases by age group and gender of injured person. A marked relationship between age and gender is evident, with young and middle-aged males and older female overseas visitors sustaining higher proportions of injuries. The greater incidence of injuries among younger male visitors can probably be explained by greater male participation in recreational and sporting activities. Indeed, further anal-
Fig. 3. Major place of occurrence categories by age group.
ysis revealed that 25 per cent of injuries to males occurred in a &place for recreation and sport', compared to just 15 per cent of female injuries. Fig. 3 shows the distribution of injuries for the major place of occurrence categories by age group. Peaks in sport and recreation injuries (40 per cent of sport and recreation injuries) and road injuries (30 per cent of road injuries) were observed for overseas visitors in the 20}29 years age group. By contrast, elderly visitors more commonly experienced injuries in the home. The distribution of event groups by gender suggests a clear delineation between the types of adventure tourism-related activities male and female overseas visitors were undertaking at the time of their injury. Females, for example, were considerably over-represented amongst horse riding accidents, contributing some 72 per cent of injuries resulting from falls from horses. Male overseas visitors, on the other hand, were over-represented in cycle (65 per cent of all cycle injuries); watercraft (70 per cent); aviation (64 per cent) and struck by/strike against events (many of which were contact sports injuries) (72 per cent). These "ndings, together with those for age distribution reported above, suggest the most appropriate targets for safety communications and other
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measures to reduce the incidence of speci"c adventure tourism and recreational injuries.
4. Discussion Recreational and adventure tourism injuries made a signi"cant contribution to overseas visitor morbidity over the 15-year period up to December 1996, with one in every 12,000 visitors to New Zealand (8.4 injuries per 100,000 arrivals) being admitted to hospital following a recreational/adventure tourism-related incident. It can be argued that this "gure is unacceptable given the relatively low exposure of tourists to recreational tourism activities in comparison to road travel, an activity for which approximately 1 in every 8300 overseas visitors was injured during the same period (12 injuries per 100,000 arrivals). Skiing, mountaineering and tramping together comprised 10 per cent of all overseas visitor injuries. It is noted these activities most commonly involve independent adventure activity, rather than organised commercial/guided adventure tourism. These "ndings are in-line with those reported for mountain recreation fatalities (Johnston, 1989; Bentley et al., 2000), and suggest that the independent adventurer should be the major target for safety communications and other interventions to reduce injury risk amongst overseas visitors to New Zealand and other countries. Such information should target high-risk travellers (i.e. travellers in the 18}35 age range), and should contain messages about the risks of travelling alone or without a guide, the level of experience and skill required to participate safely, and the fast-changing nature of New Zealand's mountain and marine environmental conditions. There are a number of opportunities to present safety information regarding potentially hazardous recreational pursuits to targeted travellers. These include: at country of origin medical centres (often visited for pre-travel vaccination); at airports and in in-#ight entertainment and information literature; at destination visitor centres, accommodation and travel o$ces (i.e. backpacker establishments, overnight huts and ski lodges); and at the point at which activities are provided or commenced. Other activities making notable contributions to tourist injury morbidity included horse riding (2.6 per cent of all injuries) and cycling (2.8 per cent of all injuries), although the proportion of cycle accidents involved organised cycle tours or mountain biking activities is unknown. White water rafting, jet boating and kayaking together contributed just 1.2 per cent of all overseas visitor injuries, this "gure being somewhat surprising given government "gures which suggest that between 100,000 and 200,000 overseas visitors participate in these water-based activities annually (New Zealand Tourism Board, 1993).
The "ndings of this research support those of previous studies considering adventure tourism safety in New Zealand (Bentley et al., 2000), indicating that activities for which there is a lower &perceived risk' but a relatively high &actual risk' (e.g. horse riding and cycle tours) should be the focus of industry attention to improve the standards of safety for participants. The best means of achieving higher standards of safety in these sectors is to introduce regulatory codes of practice, detailing issues such as level of training, quali"cations and experience required for guides, appropriate client}guide ratios, equipment speci"cations and the use of personal protective equipment. While industry-led voluntary codes of practice for these and other adventure tourism activity sectors have recently been put in place, these data indicate the need to revisit the issue of regulation versus industry self-regulation in the New Zealand adventure tourism industry (Ministry of Commerce, 1996; Page & Meyer, 1996). There is also considerable scope for adventure tourism operators and providers of recreational activities to take action to raise the standard of client safety. Operators should ascertain whether their clients have su$cient knowledge, experience, "tness levels and understanding of potential dangers, before allowing participation in their activity. Communicating safety instructions may be particularly problematic due to language and cultural di$culties. The challenge for operators is to ensure all key safety information is fully understood by participants in their activity, as it may be too late to relay safety instructions to a client once the activity is underway. Further measures that operators of adventure and recreational activities can take to improve client safety include careful choice of route and terrain to minimise the risk of slip, trip and fall injuries (the most common accident type in adventure pursuits, Bentley et al., 2000), and ensuring all participants are provided with footwear and clothing appropriate for prevailing underfoot and weather conditions. The application of operational risk management (McKay, 1998) to adventure activities should ensure all risks are identi"ed, assessed and, where potential for injury exists, removed or ameliorated. The study methodology is subject to a number of limitations, the most important of which is that the data on which it relies (NZHIS mobidity data) represent only those injuries resulting in visits to New Zealand public hospitals. The extent of unreported injuries, or injuries that resulted in treatment in the injured person's country of origin, is unknown. Furthermore, it is likely that certain visitor groups will be less likely to report injuries than others, notably the young and other &budget' travellers who are less likely to carry travel insurance and hence less inclined to visit a New Zealand hospital. Despite this potential source of bias in the "ndings reported here, tourists most likely to fall within the &budget traveller' age group (i.e. 20}30 years) are over-represented in
T. Bentley et al. / Tourism Management 22 (2001) 373}381
sport and recreation injury statistics, suggesting further evidence for this being a high-risk population. The unavailability of data for overseas visitor morbidity for the period 1997 to date is regrettable. In particular, the absence of data for this period impacts on our inability to determine whether patterns and trends in injury incidence mirror the rapid growth in certain sectors of the New Zealand adventure tourism industry over recent years. It should be noted, however, that New Zealand is unique in having a national morbidity data collection system, albeit somewhat slow in its ability to provide annual clean data sets to researchers. Further research is to investigate the injury experience of a large sample of overseas visitors to New Zealand. As well as providing support for this and previous work on adventure tourism safety, the "ndings should provide comprehensive data on the causes of injury among overseas visitors. This research, together with other work focusing on di!erent aspects of tourist safety in New Zealand, should help us better understand the health and safety needs of overseas visitors to New Zealand, and how intervention strategies can most e!ectively impact on tourist safety.
Acknowledgements Research costs associated with this research were funded by a Massey University College of Business Research Grant. The Injury Prevention Research Unit is funded jointly by the ACC and Health Research Council of New Zealand. The authors are grateful to the New Zealand Health Information Service for providing the hospital discharge data used in this study. The views and opinions expressed in this paper are those of the authors and do not necessarily re#ect those of the above organisations.
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