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Date: August 17, 2022

Title: Understanding Youth Sport Coaches’ Perceptions of Evidence-Based Injury Prevention Exercise Programs

Presenter: Lauren Hawkinson, MA, LAT, ATC

INTRODUCTION:

(Kirsten Ambrose): Hello, and welcome to the Osteoarthritis Action Alliance Lunch and Learn Webinar for August 17^th, 2022. My name is Kirsten Ambrose, and our presenter today is Lauren Hawkinson.

Ms. Hawkinson is a third-year doctoral student at the University of North Carolina Chapel hill. She earned a bachelor’s degree in athletic training from Winona State University and a Master’s Degree in Exercise and Sports Science, with an emphasis in Athletic Training from the University of North Carolina at Chapel hill.

Prior to returning to Chapel hill to pursue a PhD in Human Movement Science, Lauren worked clinically as an athletic trainer at the University of Richmond and the University of Wisconsin – Madison. Her research area of interest is the development of successful implementation strategies for ACL injury prevention programs in a variety of youth sport settings. Outside of grad school, Lauren enjoys college sports, reading, and playing the piano.  

We are excited for our presentation today titled: Understanding Youth Sport Coaches’ Perceptions of Evidence-Based Injury Prevention Exercise Programs. Welcome Lauren.

PRESENTATION:

(Lauren Hawkinson): Thank you Kirsten and thank you everyone for joining me today. I’m really excited to talk with you all about the scoping review that I conducted over the course of the last year. Before I go any farther into the presentation, I do want to thank my coauthors on this project, even though I’m the one giving the presentation today, I would not be here without the people that you see listed here, they were all instrumental in building this project, and I want to acknowledge their contributions.

ACL reconstruction rates continue to rise, among adolescents-so that 13- to 17-year-old age group-particularly among 13- to 17-year-old females.

And Herzog et al. found that females in that age group had comparable rates of reconstruction to males in that 13- to 17-year-old age group and reconstruction rates that were lower than males in the 18- to 30-year-old age group. However, by 2014 the rise in reconstruction rates among 13-to-17-year-old females had risen so sharply that they now had the highest ACL reconstruction rate than any other sex strata. As 75 to 80% of ACL injuries are non-contact in nature, there are evidence-based injury prevention exercise training programs that are focused on improving neuromuscular control, and these programs improve that neuromuscular control through the incorporation of balance, agility, strength, plyometric, and flexibility exercises. And when those programs are done consistently and correctly, they’re capable of reducing the risk of ACL injury by up to 62%, which is great news. However, even though we know that these programs are successful in reducing that rate of injury, only about 20% of US sports coaches currently implement them with their teams.

So, it’s important to gain an understanding of youth sport coach behavior and motivation to implement these injury prevention programs. So traditionally we’ve had a focus on that implementation phase of the implementation process that’s the active implementation. However, I’d like you to think of capital, I implementation and then lowercase or little I implementation. Big I implementation is going to be that full multi-phase process, however, like I said we’ve traditionally just looked at it as one phase, which is really just that little I implementation phase…that actual putting the program into practice and we’ve done a great job determining which exercises will be most effective and developing and using frameworks for that little I implementation.

However, we also need to understand the phase just prior to implementation, this phase prior to implementation has been identified by Allison Mets as the installation phase. And this stage is often overlooked, but it’s really crucial to prepare individuals for that active implementation phase. So, the purpose of the scoping review was to explore and summarize the current literature that examines youth sport coaches’ knowledge beliefs and contextual perceptions surrounding injury prevention training program implementation. Our ultimate goal is to use these findings to provide some direction for future research which is aimed at identifying appropriate strategies to increase the implementation of injury prevention training programs. To organize our findings for this scoping review we utilized the implementation science framework, called the theoretical domains framework or the TDF.

So, just a brief overview of the TDF here, it is an implementation science framework that’s used to identify individual barriers and facilitators to implementation. Overall, there are a total of 14 domains, and those are listed here. Nestled under each of those domains are constructs, some of which I will outline in an upcoming slide. But in the current review the results of the included studies fell under these four domains: knowledge, beliefs about capabilities, beliefs about consequences, and environmental context and resources. Additional domains which I’ve highlighted here: skills, goals, social influences, social and professional role, and identity may also be important in terms of encouraging coaches to implement injury prevention training programs. There was little to no evidence of these domains available within the included studies, so this perhaps indicates that there’s a need to evaluate these factors further in our future research. So, as I mentioned the four domains under which the results of the included studies fell were knowledge, beliefs about capabilities, beliefs about consequences, and environmental context and resources. Highlighted here are the definitions of the domains that were utilized in this review, and I’ll just give you a quick minute to read through these definitions, as these definitions were important when we were trying to categorize our results.  Alright, so, in addition to using the definitions on the previous slide when we categorize the study results, we also use the constructs that are listed here. So, for example, if you look under the knowledge domain, if the results of a study indicated that coaches identified incorrect exercises to include an ACL injury prevention training program, this fell under the construct of procedural knowledge. In this specific example, it would be a lack of procedural knowledge and then under the belief’s domain. If coaches thought that the implementation of an injury prevention program would reduce injury, then that would fall under outcome expectations construct.

And then finally looking over to the environmental context and resources domain coaches mentioned a lack of support from administration to attend continuing education programs, then this fell under the construct of organizational culture and climate.

Here is the process that we used when conducting literature search and determining which articles would be included. If you’re interested, you can scan that QR code down in the bottom right corner, to see a reference list of the included studies. I conducted an electronic database search using PubMed and Google scholar to identify the studies for inclusion. Articles were excluded if they did not include the knee, had no mention of ACL injury prevention programs, and did not evaluate knowledge attitudes or beliefs of coaches at the youth sport level (we identified the youth sport level as ages nine to 18).

Overall, 19 studies were included in our final review. Unfortunately, very few of the included studies reported on coach demographics that affect social determinants of health, only four reported coach education level, two reported rural vs urban location of teams and only one reported the race or ethnicity of the coaches that they surveyed.

100% of the included studies looked at knowledge and beliefs and 79% evaluated the environmental context and resources domain of the injury prevention programs that were used in the studies. 58% were just a general lower extremity injury prevention program 26% of the studies evaluated. And 16% of the studies looked at other specific programs so, for example, in one they looked at was called the activate program and the other was the control. Of the 19 studies included 84% utilized a behavioral theory and/or an implementation science framework. The behavioral theories that were used included the health belief model theory of planned behavior and the Trans theoretical model. Some examples of the implementation frameworks that were used include the rename framework which looks at reach effectiveness adoption, implementation and maintenance of programming. They also use the help action process approach or the precede-proceed model. Finally, 84% of the studies that were included in this review focused only on basketball and or soccer coaches and over half of the research was completed outside of the United States, and that was also then within independent or non-school associated elite sport organizations.

So, what do the results of this scoping review tell us about youth coach knowledge attitudes and beliefs about injury prevention training programs?

The good news is that coaches generally have a very positive attitude towards ACL injury prevention training programs and believe that if they do use them their athletes will be at a lower risk of injury. However, the self-efficacy among coaches regarding their ability to deliver the program was mixed it was even evaluated. There was also a general lack of knowledge among youth sport coaches, so many did not know of the existence of injury prevention training programs. And then, if they did know of their existence, they were unlikely to be able to identify the exercises that would be most effective to include in that Program. Additionally, they were not comfortable in properly instructing their athletes on completion of those exercises. However, although they lack knowledge coaches are aware that they lack this knowledge and would like to improve. If we take a look at the environment and resources domain, they perceive a lack of availability and education educational programming. And if they are aware of availability of this kind of programming the coaches felt that they didn’t have much administrative support to attend those programs. And finally, under that environment and resources domain, we can see the more commonly cited barriers to implementation of ACL injury prevention programs, such as time, space, equipment, financial support.

So big picture, these findings demonstrate that information about injury prevention training programs and their effectiveness to prevent ACL injury has not fully reached that youth sport coach level. There’s varying degree of knowledge among coaches about those risk factors and consequences of ACL injury as well as inconsistent knowledge of the interventions available to reduce risk and how to successfully implement these interventions. Although there are programs out there to enhance coach knowledge of ACL injury prevention, the perception, the general perception among coaches, is that they don’t exist. And then, if they are aware of these opportunities, they feel a lack of support from administration to attend.

So, moving forward, it’s essential to develop accessible, appropriate, feasible mechanisms to broaden youth sport coaches’ knowledge on the impact that participation in an ACL injury prevention training program can have on their student athletes. So, we think back to the theoretical domains’ framework in our present study knowledge, environmental context and resources, and then secondarily that beliefs domain, with the focus on self-efficacy. There appear to be the three domains, for which we should identify some corresponding strategies to enhance implementation. The really cool thing about the theoretical domains’ framework is that the creator of the TDF Susan Michie has also created a mechanism to match specific strategies to domains to those barriers and facilitators that are identified under each domain. And this matching strategy has previously been successful when trying to implement programming within school settings.

So, for example, there was a nationwide nutrition program in Australia, and it had extremely low uptake. However, following a targeted strategy intervention, once the researchers use the TDF to identify barriers and facilitators matched strategies to those barriers and facilitators, and implemented those strategies in the school following the implementation of those strategies, there was a significant increase in the number of healthy items that were offered at the in the school cafeteria, and a decrease and unhealthy items. Just an overall increase in compliance with a program overall. So, if we shift back to our results, if we use this matching of strategies to the domains, there were approximately 11 strategies that will be effective to target those domains of knowledge environmental context and resources and beliefs. I’ve just listed three examples of strategies here like I said there’s several more so, we have some options of strategies to implement with coaches.

We also know that we’d like our outputs to be an increase in readiness to implement among coaches, which we then hope leads to actual implementation and ultimately, the reduction in risk of ACL injury, but I think the question now is how do we fill that mechanisms piece, what mechanisms do we need to bridge that gap between using those strategies and successfully moving us to those outcomes of coach readiness and implementation? So, how do we effectively put those strategies to use among youth sport coaches? Generally, the place to start is in the development of the trainer mechanism, and this would be targeted specifically at coaches in the school organized youth sports setting in the United States. As evidenced in the current review there’s little known about this demographic-a lot of the research has taken place outside of the US a non-school sport setting-so it’s really important that future research evaluates the needs of the coaches in this school setting and develop an understanding of what their motivations are to ensure that the packaging of whatever implementation strategies we settled on is acceptable, appropriate and feasible for them. Based on the limited research done within this demographic we anticipate that it will be similar to what we found in the study of targeting knowledge environmental factors and self-efficacy. But I would really like to emphasize that the continued use of proactive implementation frameworks and behavioral theories in the development of these train the trainer programming models will be necessary to ensure that we find the right fit. And, really important, one of the main tenants of implementation science is the involvement of stakeholders from the very beginning.

So, as we move forward it is important to include those coaches, from the beginning and include them in the development of the education programs of the injury prevention programs, and then we need their input to adapt and be flexible and changing the programs, tweaking them to fit their settings as necessary.

I’ve included the QR code on the slide again so if you’re interested in checking out a list of the studies that were included in the scoping review, you can follow that QR Code, the full text of the scoping review will be published soon in a special issue of the journal of athletic training that is focusing on the pediatric ACL so if you’d like to read more about this to keep an eye out for that.

My contact information is there on the bottom left, so please feel free to reach out if you have additional questions after we go through the Q&A today and I just like to thank you so much again for joining us.

QUESTION AND ANSWER:(Kirsten Ambrose): Thank you, that’s very interesting. We have time for a couple of questions just a reminder, you can type any questions into the chat box and also in a few minutes, you will see a poll pop up on your screen, with some survey questions, so please answer those before you leave the webinar.

QUESTION: There is one question in the chat: Emma she says this is so interesting, it seems like a big part of this needs to include buy-in from administration to allow coaches to be able to do what needs to be done, have possible solutions been addressed to look into this.

ANSWER: You are absolutely right, I really, I agree, completely it starts with administration. From the little bit of research that I’ve done into coach education programming, they are much more likely to attend educational programming if it’s being suggested or mandated by their administrators, so I think it’s important to include those administrators in the development of these programs, so what would entice administrators to send their coaches to these programs, or what would they like to see included in the program to enhance the skills of their coaches…so yeah I think that’s a really, really important point I haven’t seen too much current research or past research on the involvement of administrators, but as I mentioned, with implementation, science, and research, including all of those stakeholders is really important to develop successful strategies.

FOLLOW-UP: (Kirsten Ambrose) Thank you, yeah, and then you know we spend so much time thinking about coaches rightfully so, but athletic trainers have a big role as well, certainly when you get into high school and college sports, so how can athletic trainers be involved in increasing participation in injury prevention programs.

ANSWER CONT’D: (Lauren Hawkinson) Yeah absolutely I think especially at the high school level athletic trainers are spread so thin and it’s impossible for them to be at every sports practice, so I think athletic trainers can play a big role in being that I guess number one trainer. They can be the trainer to train the coaches in delivery of these injury prevention programs, and I think that would also help to enhance the coaches motivation to use these programs if they’re being educated and encouraged to use these programs by someone that they already have a trusting relationship with, I think that goes a long way, rather than having someone from outside the organization come in and teach the coaches, so I see the role of the athletic trainers within the organization station is super important to facilitate this.

QUESTION: Great and Leigh says very nice talk. Are their standards that coaches have to meet to be coaches and could this be mandated in the standards?

ANSWER: (Lauren Hawkinson) It depends on the state for the certain levels that coaches have to meet it was really interesting when doing this scoping review. I believe in two or three of the studies when coaches were surveyed, they actually suggested that injury prevention education, be a part of their mandated training. So it seems that coaches are open to having that be mandated piece, so I think that’s definitely an avenue, that we should explore moving forward and how, how can we affect policy to improve implementation.

COMMENT: (Kirsten Ambrose) I think that’s a great place to start and then as a side note for our attendees, we’ve appreciated Lauren’s participation in developing a Mobile App for the Osteoarthritis Action Alliances Remain in the Game Toolkit, which is designed to help coaches, athletic trainers, and even players/team captains easily develop an injury prevention warm-up that they can do in real-time on the field.

Shameless plug that Beta testing for the App will be available very soon so check that out. But my question for you, Lauren: How can athletic trainers and coaches use a tool, like a mobile App effectively in practice, and do you think this would be helpful? It seems like it really fits, or it speaks to a lot of the points you made in that pie wheel slide where coaches know this is important and, but they struggle to identify which exercises or how to instruct athletes and that kind of thing.

ANSWER: (Lauren Hawkinson) Absolutely, I think, having the App you know at their fingertips on their phone is really helpful, something that I read when doing the scoping review was that coaches would, if they went to an education program, receive a packet or a binder, but then that would just sit in their office they wouldn’t bring that out to the field with them. So, I think the development of an App and use of an App will be really instrumental in kind of bridging that gap between the education and then putting it to practice. And then from the athletic trainers’ perspective I would have found the App really helpful, particularly when I was an athletic trainer at the collegiate level, if I could have assigned exercises to my student athletes, got them logged into the App, especially when they would go home on break, so then they could track their progress. They could send me questions and that sort of thing, while I wasn’t there one-on-one to work with them, so I think there’s a lot of opportunity to use the APP and develop it out further, so I’m really excited to see where it goes.

COMMENT: (Kirsten Ambrose) We are too, and this is really encouraging, we built in some functionality lately like you’ve described…being able to assign workouts to your players…but you’ve given us some good thoughts for how we can make that even a little bit more interactive going forward so we’ll keep that in mind.

CONCLUSION:

(Kirsten Ambrose): We have just a couple more minutes…I don’t see any other questions in the chat, but we’ll give people a chance to ask them. In the meantime, I’ll quickly just put in a plug for next month’s webinar on September 21 that will have Ashley Buck, who will be presenting “Mind the Gap: Exploring Nutritional Health and Weight Management Interests of Individuals with Osteoarthritis.” So, tune in for that! And you probably saw the poll just launched on your screen, so if you could take a moment to answer those questions that would be great. And without seeing any additional questions, I just want to thank everyone for your attendance today and the good questions that came through, I think that always helps us have a good discussion and generate some new ideas. I especially want to thank our presenter Lauren Hawkinson, we very much Appreciate your time and the work that you’re doing in this area.

(Lauren Hawkinson): Thank you so much, it was great to present.

(Kirsten Ambrose): Excellent! Well, that concludes today’s presentation. Hope everybody has a great day.