Institutionalization of sports safety: lessons from Swiss youth sports promotion programme

Arnold Tobias¹, Duarte Marcelo¹, Balthasar Andreas¹, Bürgi Flavia², Niemann Steffen²,
Thüler Hansjürg², Brügger Othmar²
1 Interface Policy Studies Research Consulting, Lucerne, Switzerland
2 Swiss Council for Accident Prevention BFU, Bern, Switzerland

Abstract

This study investigated whether instructors applied safety recommendations from the Swiss national programme for sports promotion, called Youth+Sports (Y+S), in training courses/camps with young people. Moreover, we analysed factors that affected the awareness and application of those recommendations. The analysis was based on an online survey of Y+S instructors and Y+S experts (responsible for training instructors), as well as interviews with the education managers of sport associations. We found that two-thirds of Y+S instructors were familiar with the safety recommendations in their sport, and nearly half of the Y+S instructors put the recommendations into practice. A key finding was that, in sports with special safety regulations, instructors had higher awareness and more frequently applied the safety recommendations in the practice. Differences among instructors were partly explained by the institutionalization of the safety recommendations for the sport. Thus, our findings emphasised the importance of a good educational system for successful implementation of safety recommendations in supervised youth sport activities. Compulsory guidelines for the education of Y+S instructors should be established on a high institutional level to guarantee the dissemination of preventive measures from the education managers (at the top) to the Y+S instructors (at the bottom) of sport associations.

Zusammenfassung

In dieser Studie wird untersucht, ob die Sicherheitsempfehlungen des nationalen Schweizer Sportförderungsprogramms Jugend+Sport (J+S) von Leiter/-innen in ihren Trainings/
Lagern mit Jugendlichen angewendet werden und wie sich Unterschiede in der Wahrnehmung und Anwendung der Empfehlungen erklären lassen. Unsere Analyse basiert auf einer Online-Befragung von 3524 J+S-Leiter/-innen und 246 J+S-Experten/-innen (zuständig für die Ausbildung der Leiter/-innen), die im Februar 2019 durchgeführt wurde. Zusätzlich wurden 21 Interviews mit den jeweiligen Ausbildungsverantwortlichen der Sportverbände geführt. Unsere Studie zeigt, dass zwei Drittel der J+S-Leiter/-innen die Sicherheitsempfehlungen in ihrer J+S-Sportart kennen. Fast die Hälfte setzte die Empfehlungen in die Praxis um. Ein zentrales Ergebnis ist, dass die Empfehlungen in Sportarten mit besonderen Sicherheitsbestimmungen eher bekannt sind und angewendet werden und dass dies zum Teil damit erklärt werden kann, dass die Sicherheitsbestimmungen in diesen Sport­arten institutionell stärker verankert sind. Unsere Ergebnisse unterstreichen somit die Bedeutung eines guten Ausbildungssystems für die erfolgreiche Umsetzung von Sicherheitsempfehlungen bei betreuten Jugendsportaktivitäten. Verbindliche Richtlinien für die Ausbildung von ­leitenden Personen sollten auf hoher Ebene institutionell verankert werden, um zu gewährleisten, dass Präventionsmassnahmen von den Ausbildungsverantwortlichen in den Sportverbänden bis zu den Personen an der Basis, die mit Kinder und Jugendlichen arbeiten, gelangen.

Introduction

Sports are the main cause of injuries in youth; > 30% of injuries in youth are sustained during sports activities [1, see also 2,3,4]. In Switzerland, among children and adolescents, as high as 45% of all accidents are sports-related [5]. Thus, injury prevention is crucial in sport activities organized for children and adolescents. Previous studies have highlighted two aspects of sports-related injury prevention. First, prevention guidelines must be institutionalized, because, according to Emery et al. [2], children and adolescents are not primarily responsible for injury prevention; rather, the government and sport associations must enforce safety measures. Second, preventive measures can only impact public health significantly, when they are widely accepted and adopted by coaches and sport participants [6].
In Switzerland, over 600 000 children and adolescents participate every year in a sport within the national programme for sports promotion, called Youth+Sports (Y+S). The Y+S programme, the largest sports promotion programme in the country, offers supervised sport activities (such as training courses and camps) for children and adolescents (aged 5–20 years) in about 70 sports. The training courses and camps are led by Y+S instructors, who are trained by Y+S experts. Every year, approximately 80 000 Y+S instructors are educated by approximately 3000 Y+S experts.
Injury prevention has become a key issue for Y+S. Thus, the Swiss Federal Office of Sports – the Federal Office responsible for the Y+S programme – collaborates with the Swiss Council for Accident Prevention BFU to create fact sheets on injury prevention in all sports in the Y+S programme. The fact sheets are distributed on paper and as downloadable pdf files. The fact sheets list the most important safety recommendations for each type of sport [7].
This study investigated whether Y+S instructors applied these safety recommendations in training courses and camps with young people. Additionally, we analysed the reasons for differences in the awareness of these recommendations among instructors. These findings will have practical implications for actors engaged in injury prevention in institutionally organised youth sports and offer clues for future studies.

Methods

Our analysis was based on a standardised, web-based survey of 3524 Y+S instructors (response rate: 41.9%) and 246 Y+S experts (response rate: 51.3%) from the three language regions (German, French, and Italian) in Switzerland, conducted in February 2019. The survey covered 13 different sports. The sports and the instructors/experts were selected as follows: First, sports with a high number of instructors/experts were chosen due to their quantitative relevance in Swiss youth sports. Second, sports with increased safety requirements were chosen due to the higher probability of the number and the severity of injuries in these sports (basis: Statistics of the Swiss Council for Accident Prevention [5]). We divided the sports into two groups, according to Y+S programme practices:

• Sports without specific safety regulations (category A): ice hockey, football, judo/ju-jitsu, children’s sports, gymnastics, floorball, and volleyball.
• Sports with specific safety regulations (category B): mountain climbing, rowing, swimming, alpine ski/snowboard, sport climbing, and sport shooting.

To allow comparisons between these two groups, a non-proportional, stratified sample of equal size was drawn from a list provided by the Swiss Federal Office of Sport (Table 1). The questionnaire included questions about demographics (sex, age, experience as instructor/expert, language region), individual sensitivity to safety issues, and personal awareness and use of the fact sheets. The questionnaire was pretested by 10 Y+S instructors and Y+S experts to ascertain the comprehensibility of the questions.
Additionally, 21 semi-structured qualitative interviews were conducted with education managers of the respective sports associations. These interviews provided information about the measures taken to disseminate the fact sheet in each sport (Table A1, Appendix).
Our analyses included the following dependent variables: the awareness of and use of the fact sheet. The independent variables were: sex, age, individual sensitivity to safety issues, and the existence of specific safety regulations within a sport. Table A2 (Appendix) shows how the dependent and independent variables were coded, for each question in the questionnaire. The empirical analysis comprised two steps. First, we tested for correlations between the variables by providing descriptive cross-tabulations. Second, we used binary logistic regression to assess the impact of each factor, by holding the other factors in the model constant. The number of Y+S experts was too small for statistical analysis, particularly in assessing differences between sports. Nevertheless, the findings from the expert survey assisted in contextualising and interpreting results from the Y+S instructors.

Results

Characteristics of the population

Table 2 shows the distributions of sex, age, and language region among instructors. Our sample of 3524 Y+S instructors was generally representative of all Y+S instructors, in Switzerland in terms of these three variables. However, older age groups were slightly overrepresented, given that 43% of respondents were at least 40 years old at the time they completed the survey, and only 35% of all Y+S instructors in Switzerland were at least 40 years old.

Awareness and use of the fact sheet

Table 3 shows the extent of awareness and use of the fact sheet among different subgroups of Y+S instructors. Among all Y+S instructors, 67% knew about the fact sheet and 42% used it in everyday practice with children and adolescents. However, some differences between subgroups were observed. First, both awareness of the fact sheet and its use were more common among older Y+S instructors and among Y+S instructors with more than 6 years of experience. Second, the more sensitive an instructor was to safety issues, the likelier it was that he/she was aware of and used the fact sheet. Third, men showed greater awareness and use of the fact sheet, compared to women. Finally, both the awareness and use of the fact sheet were more common in sports with special safety regulations (category B) compared to sports without safety regulations (category A).

Factors related to awareness and use of the fact sheet

Figure 1 shows that age, individual sensitivity to safety issues, and sports with special safety regulations (category B) had positive effects on the awareness of the fact sheet. In contrast, sex and long experience (> 6 years) did not have significant effects. We found similar results for the use of the fact sheet (Figure 2). Hence, the correlation found for years of experience in the previous section was most likely an effect of age, not experience in the Y+S programme. Moreover, the effect of sex seems to have resulted from the fact that male Y+S instructors in the sample were older than female Y+S instructors.

Figure 3 shows the size of the effects for the three variables that showed significant effects on the awareness and use of the fact sheet. We found that age and individual sensitivity to safety issues had the largest effects. Thus, the probability that instructors were aware of the fact sheet increased from 57%, for 25-year-old instructors, to around 70% for 50-year-old instructors, independent of all other characteristics. Accordingly, the probability of using the fact sheet increased from approximately 30% (25-year-old instructor) to approximately 50% (50-year-old instructor).
Importantly, 93% of all respondents were rather (numeric code = 3) or very (numeric code = 4) sensitive to safety issues (scale: 1 = not sensitive at all; 2 = rather not sensitive; 3 = rather sensitive; 4 = very sensitive). However, even this distinction made a difference in the probabilities of both awareness (8%) and use (13%) of the fact sheet, independent of other characteristics.
Figure 3 shows that the probabilities of both the awareness and the use of the fact sheet were around 6% higher in category B sports than in category A sports. Note that this difference resulted from a multivariate model which controlled for the variables age and individual sensitivity. Hence, this 6% difference was not linked to differences in instructor age or individual sensitivity between the two sport categories.

Discussion

This study revealed that two-thirds of the Y+S instructors were aware of the safety recommendations in the fact sheet for their sport within the Y+S education system. Nearly half of the Y+S instructors put the recommendations into practice. On the one hand, this is a positive finding since this number means that every year almost 40 000 Y+S instructors learn the safety recommendations and put them into practice. Y+S covers almost all youth sport activities in Switzerland, since it is the only financially supported programme of the federal government in this field. On the other hand, the results show that there is still a great potential to reach more instructors and to diffuse the recommendations even more.
Regarding the latter, it is worth thinking about why one half of the Y+S instructors were less sensitive to safety issues and how the safety recommendations could be implemented more extensively. Our findings revealed that factors on both the individual and contextual levels might affect this sensitivity.
At the individual level, we observed that Y+S instructors that were less sensitive to safety issues were also less aware of the safety recommendations and applied them less frequently in their lessons with children. This was particularly common among young Y+S instructors. Hence, we draw the conclusion that individual sensitivity to safety issues playes an important role in the successful implementation of safety recommendations. Previous studies have identified the various channels available for raising sensitivity to issues such as injury prevention. Timpka et al. [8,9] highlighted the importance of public authorities and sports associations, which could increase sensitivity with campaigns, media coverage, and examples of famous personalities (i.e., using celebrity athletes as role models; see also Ross et al. [10] for measures on a programmatic level). The present study provides evidence that argues in favour of the adoption of those methods.
At the contextual level, an important finding was that Y+S instructors in sports without specific safety regulations (category A) were less aware of and made less use of the safety recommendations, compared to Y+S instructors in sports with specific regulations (category B). Part of this variance on the contextual level could be explained by individual sensitivity, which was higher among Y+S instructors in category B sports than among instructors in category A sports. However, our statistical models revealed that a residual part of the variance was not explained by the individual, but by the context. Specifically, we identified two elements of context that could explain the differences.
The first contextual element is related to the context of the sports association. In interviews with the education managers of the sports associations, we found that fact sheets for sports with special safety regulations were more institutionalized, in several respects. First, the fact sheets were more likely to be mentioned in the framework curriculum which served as the conceptual basis of the education; second, fact sheets were included in the Y+S experts’ (that is the instructor educators’) dossiers for the course (didactic tool); and third, fact sheets were included in the course folders distributed to the Y+S instructors. Although these three measures were not exclusive to sports with safety regulations, there was a clear tendency for sports in category B to make more frequent use of these measures. Hence, a second conclusion of our study is that sport associations play a key role in the institutionalization of safety recommendations within the existing educational structure. They are located at the very first beginning of the process of dissemination. To ensure that the dissemination of recommendations does not depend on individuals, it is important that they are institutionally anchored (within the structures of the sports clubs; e.g. integration in the curriculum for the formation of educators. The second contextual element is related to the educational context, namely the educators. In the Y+S programme, they are called experts. Indeed, survey data from these experts revealed that Y+S experts in category B sports were more sensitive to safety issues and addressed the recommendations more consciously in their courses, compared to experts in category A sports (Appendix Tables A3-A5). Hence, a second conclusion of our study is that educators play a key role as disseminators of safety recommendations. It is therefore crucial to think of the dissemination as process of multiple steps that cannot solely be based on institutionalization. Educators must be aware of their important role as multipliers. This awareness must already be strengthened in their formation.
Our findings on the contextual level support the arguments of Emery et al. [2] and Timpka et al. [8]. Both those authors pointed out that the responsibility for preventing injuries did not lie primarily with the individual (here, the Y+S instructors and young participants), but rather, within the high-level structures determined by the government and sports associations. When preventive measures are specified in official documents and integrated into didactic teaching materials, the effect is expected to be more sustainable and less dependent on factors related to individuals.
Our study has some limitations. First, our findings were based on subjective answers from a survey. This method produced generalizable results that enabled us to make statements about the entire population. However, this method had some inherent weaknesses that made certain aspects difficult to examine in greater depth. In our view, a more in-depth study with qualitative methods would be useful to assess the effectiveness of individual measures in promoting institutional support. Second, our study was conducted in a Swiss population. Further research is needed to gain a better understanding of how preventive measures work in different cultural and legal contexts, taking into account – among ­other factors – differences between countries in how sports associations are organised. In that sense, our findings represent an important starting point for further investigations that focus on the work of collective actors, such as sports asso­ciations, public authorities, and Non-Governmental-Organisations (NGOs).

Conclusion

This is, to our knowledge, the first study on the implementation of safety recommendations in youth sports in a real-world setting in Switzerland. It shows that the dissemination of such recommendations does not have to depend solely on individuals (here the instructors). With adequate institutionalization at the level of the sports associations and a high awareness at the level of the instructors’ educators (here the experts), the dissemination can be additionally strengthened. Nevertheless, according to self-reporting, around the half of instructors still do not put the recommendations into practice. This points to a challenge that intervention programme literature usually describes with the term “adherence” or “non-adherence”, respectively [11,12]. McKay and Verhagen [13] argue that adherence “is a process influenced by the environment […]” and “shaped by social contexts […]”. Our findings support the notion that evidence-based, sports injury prevention alone has no effect, when it is not implemented in a real-world setting [14,15]. Thus, it is imperative that injury prevention and safety promotion in sports are adapted to the specific (cultural) context of sporting practices to ensure that the measures are actually put into practice [6,16]. While more research is needed how to increase adherence of these around 50 percent of instructors, our findings at least indicate that contextual factors, namely the sports association and the multiplicators, are key starting points.

Practical implications

• A good system for educating sports instructors is crucial for the successful implementation of safety recommendations in supervised youth sports.
• Mandatory training guidelines should be established at a high institutional level to ensure the dissemination of prevention measures from the training managers of sports federations, at the top, to the frontline implementers, at the grassroots level.
• These mandatory training guidelines should be institutionalized within sports associations, that is in any type of documentation used for the formation of persons who will later work with children and adolescents.
• Safety recommendations should be easily accessible and attractively presented in order to increase the usability for multiplicators as well as people who work with children and adolescents. New possibilities of digitalisation should be used.
• Further research is needed to identify the barriers for those Y+S instructors and Y+S experts who do not know the safety recommendations.

Acknowledgments, conflict of interest and funding

This study was based on an evaluation funded by the Swiss Council for Accident Prevention (BFU) and the Swiss Federal Office of Sport (FOSPO). The authors declare no competing interests.

Corresponding author

Tobias Arnold                                                                                         
Interface Policy Studies Research  Consulting
Seidenhofstrasse 12, CH-6003 Luzern                
Switzerland
Tel: +41 (0) 41 226 04 26
E-Mail: arnold@interface-pol.ch

References

1. Emery CA, Roy TO, Whittaker JL, Nettel-Aguire A, van Mechelen W. Neuromuscular training injury prevention strategies in youth sport: a systematic review and meta-analysis. Br. J. Sports. Med. 2015; 49:865–870. DOI: 10.1136/bjsports-2015-094639
2. Emery CA, Hagel B, Morrongiello BA. Injury prevention in child and adolescent sport: whose Resporsibility is it? Clin. J. Sport Med. 2006;16(6):514-521. DOI: 10.1097/01.jsm.0000251179.90840.58
3. Emery CA, Tyreman H. Sport participation, sport injury, risk factors and sport safety practices in Calgary and area junior high schools. Paediatr. Child Health. 2009;14(7):439-444. DOI: 10.1093/pch/ 14.7.439
4. Emery CA, Pasanen K. Current trends in sport injury prevention. Best Pract Res Clin Rheumatol. 2019;33(1):3-15. DOI: 10.1016/j.berh. 2019.02.009
5. Swiss Council for Accident Prevention BFU. Status 2020: Statistics on non-occupational accidents and the level of safety in Switzerland. Berne: BFU; 2020. DOI: 10.13100/bfu.2.384.08
6. Finch CF. No longer lost in translation: the art and science of sports injury prevention implementation research. Br. J. Sports Med. 2011;45: 1253-1257. DOI: 10.1136/bjsports-2011-090230
7. Swiss Federal Office of Sports. Merkblätter. 2022; URL: https://www.jugendundsport.ch/de/themen/sicherheit/merkblaetter.html (last downloaded: 1.2.2022)
8. Timpka T, Ekstrand J, Svanström L. From sports injury prevention to safety promotion in sports. Sports Medicine. 2006;36(9):733-745. DOI: 10.2165/00007256-200636090-00002
9. Timpka T, Finch CF, Goulet C, Noakes T, Yammine K. Meeting the global demand of sports safety. The intersection of science and policy in sports safety. Sports Medicine. 2008;38(10): 795-805. DOI: 10.2165/00007256-200838100-00001
10. Ross AG, Donaldson A, Poulus RG. Nationwide sports injury prevention strategies: A scoping review. Scandinavian Journal of Medicine & Science in Sports. 2020;31(2):246-264. DOI: 10.1111/sms.13858
11. Owoeye OBA, McKay C, Verhagen E, Emery CA. Advancing adherence research in sport injury prevention. Br J Sports Med. 2018;52: 1078-1079. DOI: 10.1136/bjsports-2017-098272
12. Emery CA. Injury prevention in paediatric sport-related injuries: a scientific approach. Br J Sports Med. 2010;44:64-69. DOI: 11.1136/bjsm.2009.068353
13. McKay C., Verhagen E. ‘Compliance’versus ‘adherence’ in sport injury prevention: why definition matters. Br J Sports Med. 2016;50(7): 382-383. DOI: 10.1136/bjsports-2015-095192
14. Donaldson A, Callaghan A, Bizzini M, Jowett A, Keyzer P, Nicholson M. A concept mapping approach to identifying the barriers to implementing an evidence-based sports injury prevention programme. Injury Prevention. 2019;25:244-251. DOI: 10.1136/injuryprev- 2017-042639
15. Bekker S, Paliadelis P, Finch CF. The translation of sports injury prevention and safety promotion knowledge: insights from key intermediary organisations. Health Res Policy Sys. 2017;15. DOI: 10.1186/s12961-017-0189-5
16. Bolling C, van Mechelen W, Pasman HR, Verhagen E. Context Matters: Revisiting the first step of the ‘sequence of prevention’ of sports injuries. Sports Medicine. 2018;48:2227-2234. DOI: 10.1007/s40279-018-0953-x

Table Appendix