«COOL AND CLEAN»: 10-year outcomes of structural prevention in the Swiss sports setting

Laubereau B¹, Dietrich F¹, Hanimann A¹, Fässler S¹, Oetterli M^1
1 Interface Politikstudien ^Forschung Beratung, Lucerne, Switzerland

Abstract

The body of evidence on structural prevention is scarce and needs further development. This study contributes to international research by analysing 10-year outcomes of a multicomponent programme promoting a healthy sports setting in Switzerland. Data were collected in 2007, 2011 and 2015, enabling a longitudinal perspective on outcomes. Telephone interviews, case studies, online-surveys and analysis of key documents and data were conducted. The programme «cool and clean» is well known and accepted by key partners. Partnering between the health and the sports sector has improved visibly and cantonal ambassadors are well established. Imparting knowledge among coaches and staff works well and the training for a responsible serving of alcohol has improved. However, the implementation of tied funding by cantonal authorities and the codification by sports organisations of «cool and clean» principles in rules and regulations proceeds slowly. Little progress has been made in implementing smoke-free outdoor areas at sport facilities, even on public premises. The study provides some evidence that the multilevel structural approach works. However, the findings suggest that it takes time to implement structural change on every level.

Zusammenfassung

Strukturelle Prävention ist wenig dokumentiert und die Evidenz bedarf weiterer Entwicklung. Diese Studie leistet hierzu einen Beitrag. Analysiert werden die 10-Jahres-Ergebnisse des Multikomponenten-Programms «cool and clean», welches ein gesundes Setting Sport in der Schweiz fördern soll. Es wurden Telefoninterviews, Fallstudien, Online-Befragungen und die Analyse von Schlüsseldokumenten und -daten durchgeführt. Die Daten wurden in den Jahren 2007, 2011 und 2015 erhoben, was eine Längsschnittperspektive der Ergebnisse ermöglicht.
Das Programm «cool and clean» ist bei den wichtigsten Partnern bekannt und akzeptiert. Die Zusammenarbeit zwischen dem Gesundheits- und dem Sportsektor hat sich sichtbar verbessert, und die kantonalen Botschafter sind gut etabliert. Die Vermittlung von Wissen bei Trainern und Mitarbeitenden funktioniert gut, und die Ausbildung für einen verantwortungsvollen Umgang mit Alkohol hat sich verbessert. Die Umsetzung der gebundenen Finanzierung durch die kantonalen Behörden und die Verankerung der «cool and clean»-Grundsätze in den Reglementen der Sportorganisationen verläuft jedoch langsam. Bei der Realisierung rauchfreier Aussen-Sportanlagen sind, auch im öffentlichen Bereich, nur geringe Fortschritte zu verzeichnen. Die Studie liefert einige Hinweise dafür, dass der mehrstufige strukturelle Ansatz funktioniert. Die Ergebnisse deuten jedoch darauf hin, dass es Zeit braucht, um den Strukturwandel auf allen Ebenen umzusetzen.

Introduction

30 years have passed since the World Health Organization published the Ottawa Charter for Health Promotion and thus introduced the concept of the setting approach to a broader audience. The importance of structural change in settings is well recognised by now, acknowledging the opportunity to implement comprehensive multilevel strategies and to provide sustainability [1,2]. National and international programmes usually focus on the settings city, school and workplace. Less attention has been given to the sports setting, even though its potential to promote and create healthy environments has been increasingly emphasised [3,2]. Being a member of a sports club and participating in sports reduce stress and help to develop personal skills. Moreover, health benefits may result from peer group experiences and positive role models [4]. The participation in organised sports is voluntary and as such the sports setting is positively connotated by young people, in contrast to the school setting, which is often based on compulsory presence [5]. However, while participation in organised sports may contribute to health in many respects, sports clubs may also foster unhealthy behaviour such as alcohol misuse and smoking due to certain social norms [3].
A range of interventions targeting different health issues have been implemented throughout the world within sports organisations. Many of these have focused on behavioural change only, neglecting the potential of structural changes to provide healthy environments for youth and the broader public [2]. As Kokko recently pointed out, health is an important issue for most youth sports clubs, but the implementation of actions has been difficult and clubs generally pursue their core-aims, such as optimising sports performance and athlete development [5].
High participation rates among young people underline the high potential of the organised sports setting for health promotion. In Switzerland, 62% of children aged 10 to 14 years and 43% of adolescents aged 15 to 19 years are members of a sports club [6]. In 2004, «cool and clean», a national prevention programme in the Swiss sports setting, was launched. The programme is backed multisectorally by the national umbrella organisation of Swiss sports associations (Swiss Olympic), the Federal Office of Sports (FOSPO) and the Federal Office of Health (FOPH) with financial support from the Smoking Prevention Fund. Swiss Olympic estimates that the programme is open to some 550 000 children and adolescents aged 10 to 20 years as well as to the individuals in charge of them [7]. «cool and clean» aims to prevent risky consumption of addictive substances including tobacco and alcohol and to promote fair play. The name of the programme reflects its mission: «cool» refers to participants’ commitment to a goal-oriented action and to fair play. «clean» stands for the rejection of doping and the abandonment of smoking as well as a responsible consumption of alcohol. To achieve these goals, the multicomponent programme makes use of a multilevel approach. On a structural level, the establishment of healthy environments is pursued while on an individual level, the programme aims to directly change behaviour.
On a structural level, «cool and clean» aims to change the social and the physical environment of youth participating in organised sports. The main goals of the programme are to change the social norms in sports clubs as well as the regulations for smoke-free outdoor sport facilities in order to offer a healthy environment for young athletes, but also for a broader community including visitors and spectators. «cool and clean» has established a cooperation with key partners in the field who are able to spread its mission. It makes use of two major axes (see Figure 1). In the private sport sector, an important line of action is to influence sports associations on a national and regional level, expecting them to influence their affiliated sports clubs. Switzerland, which is also referred to as the Swiss Confederation, is made up of 26 cantons, which are also known as ‘states’. Each canton has its own parliament, government, courts and constitution [8]. Due to the highly decentralised administrative and political structure of Switzerland, leaving most power to the 26 cantons, «cool and clean» cooperates with cantonal authorities in the public sport and health sector (sports offices and health offices, division for health promotion/prevention) who are involved in supporting and coordinating sporting or prevention activities. Cantonal authorities are also expected to promote smoke-free outdoor sport facilities for municipal operators. The programme fosters partnerships between the sport and health sector and provides financial support for contracting so-called cantonal «ambassadors». These ambassadors offer support for cantonal/ regional sports associations and sports clubs to implement the principles of «cool and clean».
The basic idea of «cool and clean» is to initiate structural change in the sports setting by diffusing its mission within the social system of sports organisations and relevant public authorities. The expected process of structural change initiated by «cool and clean» was retrospectively conceptualized for this paper. Following the diffusion theory of innovations by Rogers, adapted for health promotion by Batras [9] (see Figure 2), there are three phases of structural change outcomes in organisations and institutions, key partners of «cool and clean». In an initiation phase, awareness is raised and acceptance is sought within the organisations. The next stage, involving the organisation’s decision whether to adopt the mission, is characterised by an imparting of knowledge and partnering. In case of an adoption, an implementation phase follows in which the message is redefined for each organisation, clarified for broad use and finally routinized entailing an implementation of «cool and clean’s» mission in the core business [9]. In this study, the implementation is measured by evaluating the tied funding of cantons and the codification of «cool and clean’s» mission in sport organisations’ rules and regulations as well as the establishment of smoke-free outdoor sport facilities and responsible serving of alcohol at events and in sport camps.

Objectives

This paper aims to describe outcomes on structural change in the public and private sports setting, ten years after the launch of «cool and clean». The focus is set on outdoor sport facilities, sporting events and sports camps. The main research questions were: How aware are key partners of the mission of «cool and clean» and how well is it accepted? How do key partners implement the mission of «cool and clean»? Analyses of outcomes on behavioural change on the individual level will be presented elsewhere.

Methods

Data collection and analysis
In 2015 «cool and clean» was evaluated for the third time. Data were collected in 2007, 2011 and between the summers of 2014 and 2015 combining qualitative and quantitative methods, which is an acknowledged approach in programme evaluation [10]. We used various approaches to tackle the complex issue of structural change possibly triggered by «cool and clean». The focus is set on results from 2014/15, when telephone interviews, case studies, online-surveys as well as an analysis of key documents and routine data were conducted. Every methodological approach contributes to answering the three research questions with varying focus. The multiple-perspectives approach captures different perceptions of various target groups. The findings were compared to the results from 2007 and 2011, when available, enabling a longitudinal perspective on certain outcomes over time. All procedures performed in the evaluation were conducted in accordance with the evaluation standards of the Swiss Evaluation Society.

In 2015, semi-structured telephone interviews were conducted with persons responsible for youth sports and for training courses for coaches in the 20 biggest national sports associations, 20 clubs and with 28 operators of outdoor sport facilities. These 20 national sports associations represent 13 700 affiliated sports clubs. 19 interviews were conducted with cantonal ambassadors. The interviews were recorded in audio form as well as in writing and analysed both quantitatively and qualitatively.
A case-study design is appropriate to develop an in-depth understanding of how collaborating organisers of sporting events and sport camps implement the mission of «cool and clean» into practice. Three sporting events were selected for case studies and three methodological approaches were used: on-site observations, semi-structured telephone interviews with the organisers and standardised short interviews with 16 persons responsible for serving alcohol as well as with 95 participating adolescents. Furthermore, four sports camps collaborating with «cool and clean» were selected for case studies. In-person semi-structured interviews with the heads of each camp as well as group interviews with five to six adolescent participants were conducted.
Online surveys were carried out among representatives of all 26 cantonal sports offices and 24 cantonal health offices as well as 1390 coaches participating in education classes. The survey respondents were asked to report on several topics including awareness and acceptance of «cool and clean», partnering and integration of «cool and clean’s» mission in courses and sports camps.
Additionally, a wide range of routine data and key documents (e.g. annual reports, rules and regulations) were analysed to assess the implementation of the mission of «cool and clean» by sports associations and affiliated clubs. The quantitative data were analysed using IBM SPSS Statistics version 19.0.

Results

Initiation: raised awareness and good acceptance of «cool and clean» among key partners
The interview partners from sports associations and clubs are well acquainted with the programme, as was already the case in 2011 and 2007. The awareness among sports clubs representatives has risen constantly since 2007, as estimated by representatives of the associations. 89% estimated that at least three quarters of their affiliated clubs have heard of «cool and clean», whereas in 2011 and in 2007 it was only 52% and 42% respectively. The respondents highly appreciated the programme’s concept, practical orientation and support through information material. «cool and clean» is also well accepted by the cantonal authorities, similar to the findings in 2011, especially in the sports sector. 24 of 26 sport offices (92%) and 19 of 24 health offices (79%) consider «cool and clean» to have a good reputation in their professional environment. Substance abuse, fair play and doping in sports are increasingly discussed due to «cool and clean», as estimated by 68% of cantonal representatives in 2015, compared to 43% in 2011. «cool and clean» supports sporting events organisers in the incorporation of «cool and clean» principles by providing them with consumables, loaned material and training. These principles primarily include smoke-free environments, strict compliance with laws on the protection of minors, no sponsors from the tobacco industry and bans on advertising of tobacco products. Available statistics from Swiss Olympic show 900 contacts between the «cool and clean» programme management team and sporting events organisers between 2013 and mid-2015.

Decision to adopt: partnering has improved visibly over time
The embedding of «cool and clean» in public (cantonal) authorities works well. In 20 of 26 cantons, «cool and clean» ambassadors have been employed by 2015. This is a considerable increase since 2011, when only 7 cantons made use of ambassadors. The ambassadors seem to fulfil their purpose, as 78% of the cantonal authorities state a better access to sports clubs and 94% an increase in registrations of teams and sports clubs with «cool and clean» due to the employment of ambassadors. The structural embedding of the ambassadors differs between regions. In German-speaking Switzerland, they are employed by the sports offices, whereas in the French- and Italian-speaking parts, the ambassadors are employed by the health offices. The interviews indicate that an affiliation with a sports department seems to facilitate the access to sports organisations. Overall, institutional contacts between the sport and the health sector have improved due to «cool and clean», with 64% of the sports offices confirming intensified contacts with health offices in the last four years. In addition, two-thirds of the respondents state an increasing awareness of sports organisations due to «cool and clean» that prevention agencies may offer help in case of problems.

Decision to adopt: Imparting knowledge works well
In 2014, a total of 147 sports camps run by associations or cantons were registered with «cool and clean». The imparting of knowledge works well, both in private and public camps. As reported by camp officials in a routine feedback, the programme’s commitments were made a subject of discussion in 95% of the camps. Responsible persons are trained in courses offered by the national youth and sports programme and over 80% of these are acquainted with «cool and clean». Moreover, 84% of the national sports association representatives regard themselves as multipliers of «cool and clean’s» mission, and 85% use «cool and clean» material at their sporting events, representing a higher percentage than in 2007.

Implementation: Training for responsible serving of alcohol and responsible consumption in sports camps has improved
The proportion of serving staff at sporting events receiving specific training in protection of minors from underage drinking grew considerably from 35% in 2011 to 75% in 2015. Moreover, case studies of sporting events showed that organisers were willing to comply with the rules for the protection of minors. Information signs were positioned at every point of sale and non-alcoholic beverages were sold at a lower price than alcoholic ones. The organisers were satisfied due to a lack of major incidents, and test purchases organised by «cool and clean» indicate an improvement in complying with youth protection laws compared to previous years. Moreover, in sports camps, responsible alcohol consumption was considerably improved due to «cool and clean», as reported by the representatives of cantonal sports offices (72% in 2015 compared to 30% in 2011) and confirmed by the case studies.

Implementation: Smoke-free environments are welcomed but implementation progresses very slowly
93% of the interviewees of sports associations and sports clubs are in favour of smoking bans for outdoor sport facilities and events. 80% of the national associations report that at least some of their events are smoke-free, however only 10% due to «cool and clean». In 2011, shortly after the introduction of indoor smoking bans in Switzerland, the impact of «cool and clean» was considered higher (45%). The case studies of sporting events showed no establishment of smoke-free outdoor areas at any of the three events, explained by organisers through a missing legal basis and difficulties to control the compliance with a smoking ban. Moreover, there was no ban on sales, advertising and sponsorship for tobacco products at any of the three events. In contrast, the impact of «cool and clean» on the realisation of smoke-free sports camps is considered much higher by cantonal sports offices (50%) and has increased since 2011 (30%).
Little progress has been made since 2011 concerning the implementation of smoke-free outdoor sport facilities. The respondents display a limited awareness and bans are considered either unnecessary or have not been enforced due to a lack of human resources. Even in public (municipal) facilities, outdoor-smoking bans have rarely been implemented and are mainly seen on school premises, outdoor facilities and football fields. «cool and clean» has launched a «90 minutes smoke-free» campaign in collaboration with the Swiss Football Association. The aim is to designate the field and the spectator area as smoke-free zones during youth games. According to available statistics, only 90 orders of material of the campaign and 198 orders to designate smoke-free outdoor sport facilities were placed between 2012 and 2014. There is no information available on how the material has been used and on the actual implementation of smoke-free areas. An interactive map for the self-declaration of smoke-free outdoor sport facilities operated by «cool and clean», shows 54 municipalities (of more than 2000 municipalities in Switzerland) having registered a total of 64 facilities.

Implementation: Tied funding and the codification of principles of «cool and clean» leaves room for further improvement
The implementation of binding provisions proceeds slowly, both in the public and the private sector. By 2014, only 8 of 19 cantons (‘states’) tied sponsorship of sporting events to an implementation of preventive measures such as smoke-free areas and responsible serving of alcohol. Moreover, an analysis of the rules and regulations and the annual or business reports of 20 national sports associations revealed that the codification of the mission of «cool and clean» is not well established. Both the name «cool and clean» as well as the related terms alcohol, tobacco, smoking, prevention of substance abuse and protection of minors are hardly mentioned in the documents. By 2015, 48 of 80 national sports associations (60%) had established a partnership with «cool and clean» as part of their performance agreement with Swiss Olympic. 22 of these (46%) had implemented a corresponding activity. On the clubs level, however, only 417 sports clubs had incorporated «cool and clean’s» mission in their rules and regulations by 2015.

Discussion

This study contributes to the body of evidence on effectiveness of structural change in prevention, which is still scarce, despite the acknowledged potential for sustainable health promotion [2]. Changing environments in community settings such as sports clubs are considered to facilitate healthy behaviours of active youth and, in addition, of a greater community, including spectators [11].
Our findings show that an implementation of structural change requires a substantial amount of time in order to pass through the different stages of change in private and public organisations and institutions. The first two stages according to Rogers’ theory of change [12] have been achieved by «cool and clean» after ten years. However, the third stage, an implementation in the sense of binding provisions, has not been accomplished in a desirable range, neither in the public nor in the private sector. The national programme «cool and clean» is well known and accepted by all key partners in Switzerland at the federal levels and in both the public and the private sector. Cantonal sports offices, however, express their approval of the programme slightly more often than health offices. This might reflect the programme’s rooting in the sport sector. Since 2011, the partnering between the health and the sports sector has improved visibly and the institutional embedding of «cool and clean»-ambassadors has been achieved in most cantons. The imparting of knowledge among coaches and staff responsible for sports camps and sporting events works well. Implementation in general is slow. Some findings indicate that implementation on the national level is more advanced than on the lower federal levels. A quarter of the 80 national sport associations has established a partnership with «cool and clean» as part of their performance agreement with Swiss Olympic, thus exceeding expectations. The number of clubs, which included «cool and clean’s» principles into their rules and regulations, however, has not yet measured up to expectations. Moreover some findings suggest that implementation might depend on the topic. While smoke-free environments have gained public support in the wake of legal smoking bans in Switzerland since 2010, alcohol prevention is a much more conflicting issue, suffering from low public support. In our study, this is reflected by the finding that a large majority of associations and clubs hold smoke-free sporting events and only a small minority hold alcohol-free events. However, outdoor smoking bans are still rarely implemented even though the vast majority of interviewees from sports organisations are in favour of smoking bans for outdoor sport facilities and events. On the other hand, protecting youth from alcohol consumption is well accepted in Switzerland. In agreement, our findings show that training for responsible serving of alcohol has improved. However, implementation of binding provisions, like tied funding by cantonal authorities and a codification of «cool and clean» principles in rules and regulations by sports organisations, proceeds slowly. Even though smoke-free outdoor environments are welcomed by most respondents in our study, little progress has been made since 2011 concerning the implementation of smoke-free outdoor areas at sport facilities, even on public premises. The case studies indicate that the awareness of outdoor bans and their benefits is limited.
It must be noted that Switzerland is a country with a relatively low public support for tobacco and alcohol prevention and with a weak legal base due to its federal organisation. It is among the countries with very liberal alcohol policies in Europe and scores low on the international Tobacco Control Scale which quantifies the implementation of tobacco control policies at country level. Swiss tobacco advertising legislation is weak, lacking public support, and the country has still not ratified WHO’s Framework Convention on Tobacco Control. A nationwide smoking ban for public buildings or workplaces was implemented as late as in 2010 [13,14,15]. However, even in Australia, which is a country with strict tobacco advertising bans and a broad range of health sponsorship programmes of sports organisations, the implementation of structural change took considerable time [11]. Research on organisational change underlines the need for longer time frames for intervention programmes aiming at setting-level change in comparison to individual-level change strategies [16,17].
Barriers associated with implementation have been described in some studies. Limited control over facilities, limited resources, other club priorities, perceived costs, lack of support and training and of policy examples to follow were identified as barriers [18]. Some facilitators for implementation have also been recognised. Following Rogers’ theory of change [12], it has been postulated that implementation of organisational change strongly depends on the compatibility of the new message with the core values, beliefs and priorities of the respective organisation [9]. Further positive factors include a designated person responsible for the implementation, good support of sports clubs by health agencies and resources reaching the club level [2]. Current research emphasises the importance of actively participating representatives within the sports setting [5,19]. Therefore, the programme «cool and clean» works with a multiperspective and multilevel approach.
The multilevel structural approach is very challenging in terms of evaluation of effects. It is widely acknowledged that an evaluation of structural prevention is difficult [20,2]. A limitation of this study is the restriction to descriptive analysis. Though programme evaluation was conducted on a regular basis and enables describing development over time, the data do not allow further statistical analysis. The multilevel structural approach proved too complex to be grasped comprehensively with the resources available to allow analysis of causal relations on a higher statistical level. The findings from the interviews rely on self-reporting and the information on outcomes on the club level is based on estimation of the association representatives. Originally, interview data and case-studies were to be complemented by routine data provided by the programme. In spite of the availability of a wide range of data, it became clear that the scope and quality of most data were insufficient to measure effects. Another limitation of the study is the lack of a control group. It may be disputed that effects of the programme cannot be isolated from other influences. As «cool and clean» is a very comprehensive programme acting on different levels, it is very difficult to define a reliable control group.
To meet this challenge, respondents were asked to estimate the influence of the programme on certain developments and additional data collections such as an analysis of websites were conducted. Moreover, a theory-based multi-method approach was used in order to embed the findings into a conceptual framework. In a review based on additional material and site visits, an independent scientific advisory committee, consisting of five national and international experts from the fields of public health, sports and addiction prevention concluded that the programme works well [21].
To conclude, «cool and clean» is an exceptionally comprehensive nation-wide programme which promotes health in the sports setting. The results provide some evidence that the structural approach works. However, the findings suggest that it takes a substantial amount of time to implement structural change on every level. In the future, special attention should be given to the implementation of smoke-free outdoor sport facilities, the codification of the mission by sports clubs and tied funding by public authorities.

Acknowledgements

The authors would like to thank all participating representatives of organisations and institutions and the Swiss Olympics team for providing details on the programme.

Conflict of interest

None declared.

Funding

This work was supported by the Swiss Smoking Prevention Fund as part of the evaluation of «cool and clean».

Practical Implications

• «cool and clean» is a comprehensive health promotion programme in sports with a structural approach which needs more than 10 years to effect structural change on every level.
• Even though smoke-free environments have gained public support, smoke-free outdoor areas in the sports setting are still rare and need to be extended.
• Alcohol prevention is suffering from low public support and should be further promoted in the sports setting.

Corresponding author

Birgit Laubereau, MD, MPH
laubereau@interface-politikstudien.ch
Telephone: +41 41 226 04 26
Fax: +41 41 226 04 36

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