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Work to establish effective injury prevention measures

This is an excerpt from Psychology of Sport Injury by Britton Brewer & Charles Redmond.

Models of Sport Injury Prevention


Several frameworks have emerged to guide sport injury prevention efforts. These frameworks serve as models to ensure that sport injury research and practice proceed in an organized, scientific manner. Models of sport injury prevention have been proposed by W. van Mechelen, Hlobil, & Kemper (1992), Finch (2006), and Van Tiggelen, Wickes, Stevens, Roosen, and Witvrouw (2008). The model put forward by W. van Mechelen et al. proposed a four-step framework. The first step involves identifying the magnitude of the sport injury problem and describing the incidence and severity of sport injury. The second step involves determining the etiology and mechanisms of sport injury, and the third step involves introducing preventive measures. The final step involves assessing the effectiveness of the preventive measures introduced in the third step by essentially repeating the first step - that is, checking whether the incidence and severity of sport injury have changed as a result of the preventive efforts.


Finch (2006) acknowledged that the model proposed by W. van Mechelen et al. (1992) had been valuable in guiding research on sport injury prevention and aligning it with public health approaches to injury prevention outside of sport, but she also identified a major shortcoming of the model. Specifically, it failed to consider challenges in implementing injury-prevention measures in sport settings; in fact, it completely neglected factors contributing to the adoption (or nonadoption) of preventive behavior. To remediate this deficiency, Finch proposed the six-step TRIPP framework, which is short for Translating Research into Injury Prevention Practice.


The first four steps of TRIPP resemble the four steps of the model put forth by W. van Mechelen et al. (1992). Specifically, step 1 of TRIPP consists of injury surveillance - an ongoing process of monitoring the occurrence of sport injuries in order to establish the extent of the problem and gauge progress toward achieving prevention aims. Step 2 is identical to the second step of the van Mechelen model - establishing the etiology and mechanisms of injury. Step 3 involves using a multidisciplinary approach based on theory and research to identify possible solutions to the sport injury problem and develop corresponding preventive interventions. Step 4 consists of subjecting the preventive measures generated in the third step to evaluation under "ideal conditions" - that is, laboratory or controlled clinical or field settings in which researchers deliver interventions to coaches and athletes who have been convinced and helped to participate through incentives and reminders.


In the fifth and sixth steps of TRIPP, Finch (2006) departs from the model of W. van Mechelen et al. (1992). The purpose of TRIPP step 5 is to "describe intervention context [in order] to inform implementation strategies" (p. 4). This process involves getting a sense of the real-world sport contexts in which to apply the preventive measures developed in step 3 and evaluated in step 4.Doing so requires gathering information about athletes’, coaches’, and administrators’ knowledge, attitudes, and current behaviors regarding sport safety practices. Ultimately, the critical tasks of step 5 are to determine how likely the target sport populations are to accept and adopt preventive interventions and to plan for the implementation of the interventions. In step 6, based on the information gathered in step 5, the preventive measures are implemented and evaluated in naturalistic sport settings under real-world conditions. In addition, whereas step 4 examined the efficacy of interventions, step 6 assesses their effectiveness (for more on the distinction between these two terms, see this chapter’s Focus on Research box). Despite their importance, steps 5 and 6 are underrepresented in the research literature (Klügl et al., 2010).


Van Tiggelen et al. (2008) agreed with the contention of Finch (2006) that, contrary to the model of W. van Mechelen et al. (1992), merely showing that a preventive measure reduces the incidence or severity of injury is insufficient to demonstrate the effectiveness of that measure. As depicted in figure 3.1, they argued that for a preventive measure to be found effective, additional criteria must be satisfied. Specifically, after finding the preventive measure efficacious in the fourth steps of the W. van Mechelen et al. and Finch models, it is also necessary to show that the measure displays efficiency, is complied with adequately, and does not adversely affect risk taking.


Figure 3.1 Sequence of injury prevention.
Sequence of injury prevention.
Reproduced from British Journal of Sports Medicine, "Effective prevention of sports injuries: A model integrating efficacy, efficiency, compliance and risk-taking behavior," D. Van Tiggelen et al., 42: 648-652, 2008, with permission from BMJ Publishing Group Ltd.


The first criterion, efficiency, is demonstrated when those involved in adopting and implementing preventive measures (e.g., administrators, coaches, athletes) deem that the benefits (e.g., fewer injuries, lower medical costs, fewer lost training hours, less postinjury distress) outweigh the costs (e.g., monetary expenses of prevention-related goods and services, time required to implement measures, discomfort or restricted movement when wearing protective gear). The second criterion, compliance, is satisfied when the preventive measures are introduced and are adhered to by intervention recipients. As discussed in chapter 6, the extent to which people adhere to interventions related to sport injury is influenced by a multitude of personal, social, cognitive, emotional, and behavioral factors. Compliance with preventive measures cannot be assumed, even for highly motivated athletes.


The third criterion, which involves risk-taking behavior, is satisfied by the avoidance of "risk homeostasis" (Wilde, 1998), in which the beneficial effects of prevention are offset by a corresponding increase in risk taking. It can be challenging to avoid risk homeostasis (also known as "risk compensation"), as illustrated by the following research findings: Skiers and snowboarders who wore a helmet went nearly 5 kilometers per hour faster than those who did not wear a helmet (Shealy, Ettlinger, & Johnson, 2005); children who wore safety gear proceeded through an obstacle course featuring various hazards faster and more recklessly than those who did not wear safety gear (Morrongiello, Walpole, & Lasenby, 2007); and athletes in collision sports (e.g., hockey, rugby) reported that they play more aggressively when wearing protective gear (C.F. Finch, McIntosh, & McCrory, 2001; Woods et al., 2007). The dangerous behavior that characterizes risk homeostasis may be underlain by erroneous beliefs about the protective capabilities of safety gear (Chaduneli & Ibanez, 2014).

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