Original article

Br J Sports Med: first published as 10.1136/bjsports-2014-093543 on 13 June 2014. Downloaded from http://bjsm.bmj.com/ on November 8, 2023 by guest. Protected by copyright.
The effect of coach and player injury knowledge,
attitudes and beliefs on adherence to the
Editor’s choice
FIFA 11+ programme in female youth soccer
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Carly D McKay,1 Kathrin Steffen,2 Maria Romiti,1 Caroline F Finch,3

free content

Carolyn A Emery1,4,5,6

▸ Additional material is ABSTRACT these strategies.12–15 Yet, there has been limited
published online only. To view Background Injury knowledge and beliefs influence attention given to factors that could promote pro-
please visit the journal online
(http://dx.doi.org/10.1136/ uptake of prevention programmes, but the relationship gramme adherence.16 One potential factor is
bjsports-2014-093543). between knowledge, beliefs and adherence remains knowledge regarding injury risk and prevention.
1 unclear. Orr et al17 examined youth soccer coach and
Faculty of Kinesiology, Sport
Injury Prevention Research Aim To describe injury knowledge and beliefs among player knowledge of knee injury and safety prac-
Centre (SIPRC), University of youth female soccer coaches and players, and to identify tices, and found significant gaps in understanding
Calgary, Calgary, Alberta, the relationship between these factors, different delivery of knee injury prevention in coaches and players.
Canada strategies of the FIFA 11+ programme and adherence. This observation is consistent with previous studies
2
Department of Sports
Medicine, Oslo Sports Trauma Methods A subcohort analysis from a cluster- that have found limited injury awareness among
Research Centre, Norwegian randomised controlled trial of 31 female soccer teams coaches18–21 and athletes22–24 in a variety of sports.
School of Sport Sciences, Oslo, (coaches n=29, players (ages 13–18) n=258). Preseason There is a paucity of research examining how
Norway and postseason questionnaires were used to assess coach and player knowledge directly influences
3
Australian Centre for Research
knowledge and beliefs. Teams recorded FIFA 11+ injury prevention behaviour.25 Arnason et al26
into Injury in Sport and its
Prevention (ACRISP), Federation adherence during the season. demonstrated that increasing injury awareness did
University Australia, Ballarat, Results At baseline, 62.8% (95% CI 48.4% to 77.3%) not reduce injury rates in a sample of elite male
Australia
4
of coaches and 75.8% (95% CI 71.5% to 80.1%) of soccer players, but did not measure the effect of
Faculty of Medicine, players considered ‘inadequate warm-up’ a risk factor for awareness on players’ prevention behaviour. In a
Department of Pediatrics,
Alberta Children’s Hospital
injury. There was no effect of delivery method (OR=1.1; study of Premier Division Australian football,
Research Institute for Child and 95% CI 0.8 to 1.5) or adherence (OR=1.0; 95% CI 0.9 coaches had poor knowledge of lower limb injury
Maternal Health, University of to 1.1) on this belief. At baseline, 13.8% (95% CI 1.3% prevention strategies and did not routinely incorp-
Calgary, Calgary, Alberta, to 26.4%) of coaches believed a warm-up could prevent orate prevention strategies into their training ses-
Canada muscle injuries, but none believed it could prevent knee sions.19 Fewer than 75% of players training with
5
Faculty of Medicine,
Department of Community and ankle injuries. For players, 9.7% (95% CI 6.1% to these coaches believed that balance, landing or
Health Sciences, University of 13.3%), 4.7% (95% CI 2.1% to 7.3%) and 4.7% (95% cutting exercises had injury prevention benefit, and
Calgary, Calgary, Alberta, CI 2.1% to 7.3%) believed a warm-up would prevent only 74% would be willing to perform injury pre-
Canada muscle, knee and ankle injuries, respectively. Years of vention exercises during training.27 However, with
6
Faculty of Medicine, Hotchkiss
Brain Institute, University of
playing experience were negatively associated with high such limited evidence, the extent to which coach
Calgary, Calgary, Alberta, adherence for coaches (OR=0.93; 0.88 to 0.99) and knowledge influences prevention behaviour among
Canada players (OR=0.92; 0.85 to 0.98). their players is not yet clear.
Conclusions There were gaps in injury knowledge and Attitudes towards injury risk and prevention are
Correspondence to
beliefs, which differed for coaches and players. Beliefs did also associated with the uptake of preventive mea-
Carly D McKay, Faculty of
Kinesiology, Sport Injury not significantly affect adherence to the FIFA 11+, sures among coaches28 29 and youth sport partici-
Prevention Research Centre suggesting additional motivational factors should be pants.22 30–36 Perceived susceptibility to injury,30 36
(SIPRC), University of Calgary, considered. social influences30 32 35 and dislike of prevention
Calgary, Alberta, strategies30 31 36 have all been shown to influence
Canada T2N 1N4;
cdmckay@ucalgary.ca prevention behaviours in a variety of competitive
BACKGROUND and recreational sports. Specifically, lack of per-
Received 6 February 2014 In Canada, soccer injuries account for over 10% of ceived need,30 social pressure32 35 and protective
Revised 14 May 2014 all sport injuries in youth aged 11–18 years.1 equipment discomfort36 have been associated with
Accepted 28 May 2014
Several studies have demonstrated the injury pro- poor adherence to preventive interventions.
Published Online First
13 June 2014 tective effect of a neuromuscular training warm-up Additional factors, such as age, may influence these
programme in youth soccer2–8; however, the attitudes.30 In youth soccer specifically, there is also
success of these programmes when implemented in some evidence that female players report higher
the context of real-world sports is dependent on levels of perceived injury risk than male players.37
coach and player adherence. Higher adherence has Interestingly, direct exposure to injury prevention
been shown to positively correspond to greater programmes may not be sufficient to change injury
injury protective effects.9–11 Despite this, adherence prevention attitudes. Gilchrist et al38 found that
to effective injury prevention measures is an participating in injury prevention did not influence
To cite: McKay CD, ongoing challenge in community sport settings. soccer coaches’ knowledge, attitudes, beliefs or pre-
Steffen K, Romiti M, et al. There is an established need for more implemen- vention behaviours across a season.
Br J Sports Med tation research on sport injury prevention pro- The effect of a preventive intervention on coach
2014;48:1281–1286. grammes to maximise adherence and uptake of and player attitudes and beliefs has not yet been

McKay CD, et al. Br J Sports Med 2014;48:1281–1286. doi:10.1136/bjsports-2014-093543 1 of 7

 Original article

Br J Sports Med: first published as 10.1136/bjsports-2014-093543 on 13 June 2014. Downloaded from http://bjsm.bmj.com/ on November 8, 2023 by guest. Protected by copyright.
examined in youth soccer, and the relationship between knowl- programme instruction information about the programme’s
edge, attitudes and adherence to injury prevention programmes development and purpose) and copies of FIFA 11+ material
remains unclear. The purpose of this investigation was therefore (DVD, poster detailing the exercises, website information). In
twofold. First, the study aimed to describe the baseline levels of addition to a preseason FIFA 11+ workshop for coaches and
injury knowledge, attitudes and beliefs among coaches and receiving copies of the FIFA 11+ material, teams in the ‘com-
players. The second objective was to determine the relationship prehensive, player-focused intervention group’ were also
between intrinsic coach and player factors (ie, personal assigned a study physiotherapist who taught the 11+ pro-
characteristics and beliefs), different delivery strategies of an gramme to the players and participated regularly in practice ses-
injury prevention warm-up programme and adherence to the sions to facilitate correct technique and progression.39 All
intervention over the course of one competitive season. participating coaches were asked to perform the FIFA 11+ pro-
gramme with their team as a warm-up at the beginning of all
METHODS practice and match sessions, at a suggested minimum of two to
This study is a secondary analysis of data from a cluster- three times per week.
randomised controlled trial (cRCT)39 investigating the effect of
different delivery methods of the FIFA 11+ injury prevention Daily exposure sheet
warm-up programme3 on adherence, player injury risk and During the season, exposure and adherence data were collected
player performance. The overall design and methods of the prospectively using a modified version of a previously validated
cRCT are reported elsewhere.39 exposure registration form for injury surveillance in youth
soccer.41 All teams appointed a team designate who was respon-
Participants sible for recording individual exposure at each practice and
The sample was recruited from a target population of 31 female match session, as well as team-level adherence to the FIFA 11+,
soccer teams ( players aged 13–18 years) competing in the 2011 using the daily exposure sheet.39 Coach adherence was operatio-
outdoor season. These teams represented 18 clubs from the top nalised as the proportion of team training sessions and games at
three competitive levels (tiers 1–3) of the Calgary and which the FIFA 11+ exercises were performed. Player adher-
Edmonton Minor Soccer Associations and the Edmonton ence was based on the proportion of sessions at which the team
Interdistrict Youth Soccer Association in Alberta, Canada. performed the FIFA 11+, adjusted for individual attendance at
All participants provided informed consent prior to the start those sessions. Coaches and players were divided into ‘low’
of study as per the Office of Medical Bioethics, University of (<72% of sessions), ‘medium’ (72–91% of sessions) and ‘high’
Calgary. (≥91% of sessions) adherence tertile groups.

Attitudes and beliefs questionnaire

Coaches and players completed a paper-based questionnaire Analysis
assessing their coaching/playing experience, injury history, and All analyses were performed using STATA V.12.0 (StataCorp;
attitudes, beliefs and knowledge about injury risk and injury College Station, Texas, USA). Baseline questionnaire responses
prevention in youth soccer. This was administered during base- were descriptively analysed including all respondents, regardless
line performance testing sessions early in the soccer season and of whether they completed a postseason questionnaire.
again at the conclusion of the 4-month season, allowing an Descriptive analyses are reported as proportions with 95% CIs
assessment of changes in attitudes and beliefs resulting from or medians with ranges and IQRs. Lower limits of the 95% CIs
exposure to the FIFA 11+ during the season. were truncated at zero, when necessary.
The questionnaire was based on a previously developed Analysis of changes between baseline and postseason were
survey of junior netball coaches in Australia.28 40 There were restricted to respondents who completed questionnaires at both
separate coach and player versions of the questionnaire, and time points. Knowledge, attitudes and belief changes from base-
both underwent face validation. The player questionnaire was line to postseason were estimated using McNemar’s χ2 tests.
also pilot tested among a team of youth soccer players involved Logistic regression (yielding OR with 95% CIs), adjusting for
in an independent youth soccer study in a neighbouring prov- cluster by team, was used to examine the effect of intrinsic
ince. Based on this pilot test, some items were rephrased as factors (age group, competitive level, years of soccer coaching/
required. The study questionnaire is available as online supple- playing experience, 1-year injury history), FIFA 11+ delivery
mentary content. method and adherence on postseason injury attitudes and
beliefs. Logistic regression, adjusting for cluster by team, was
Different delivery methods of the FIFA 11+ also used to examine the effect of intrinsic factors and delivery
The FIFA 11+ is a 20-min warm-up programme developed by method on adherence to the FIFA 11+ programme.
FIFA Medical Assessment and Research Centre (F-MARC) to
prevent lower extremity injuries among soccer players, consist- RESULTS
ing of 15 single exercises with a focus on cutting, jumping and Participant characteristics
landing technique, and on strength, plyometrics, agility and field Participant flow through the study is presented in figure 1.
balance components.3 Following baseline questionnaire comple- Forty-three (91.5%) coaches and 385 players (100%) provided
tion, teams were cluster randomised to one of three intervention questionnaire responses in the preseason period. Twenty-nine
groups to evaluate the effect of different delivery methods of coaches (61.7%) and 258 (67%) players completed question-
the FIFA 11+ on adherence.39 naires at both time points.
Coaches from teams randomised to the ‘control’ group were Baseline coach and player characteristics are presented in
provided with details for online access to the FIFA 11+ pro- table 1. The coach sample consisted of 24 head coaches, 21
gramme website (http://f-marc.com/11plus/). Coaches rando- assistant coaches and 2 team managers (47 ‘coaches’), but only
mised to the ‘regular, coach-focused intervention group’ were 43 of these individuals provided baseline characteristic
provided with one preseason 11+ coach workshop (including information.

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Figure 1 Proportion of coaches and
players responding to the baseline and
postseason questionnaires, by
randomised group.

Baseline injury beliefs Effect of personal characteristics and

Injury risk beliefs 11+ exposure on beliefs
At baseline, 30.2% (95% CI 16.5% to 44.0%) of coaches and Adherence
27.8% (95% CI 23.3% to 32.3%) of players believed that male Mean team-level adherence to the FIFA 11+ was 73.5% (95%
and female soccer players had the same overall risk of injury. CI 67.4% to 79.6%) for teams in the ‘control’ group, 81.3%
Beliefs about specific injury risk are presented in table 2. (95% CI 75.7% to 86.9%) for teams in the ‘standard’ group
Coaches and players selected the category ‘knees and ankles’ as and 85.6% (95% CI 81.8% to 89.4%) for teams in the ‘com-
the most commonly injured body parts. prehensive’ group.

Injury risk beliefs

Injury prevention beliefs More players than coaches considered ‘inadequate warm-up’ as
The three injury types (as identified by participants) that were a risk factor for injury at postseason (table 2). Adjusting for
most commonly believed to be preventable were ‘muscle injur- team role (coach or player), there was no effect of randomisa-
ies, ‘knee injuries’ and ‘ankle injuries’. The most frequently indi- tion group (OR=1.1, 95% CI 0.8%to 1.5%) or adherence
cated strategies to prevent these injuries are presented in table 3. (OR=1.0; 95% CI 0.9% to 1.1%) on the belief that inadequate
When asked directly whether they believed that injuries were warm-up was a risk factor.
preventable, coaches were more likely than players to answer
‘yes’ (z=−3.90, p=0.0001). Attitudes towards who should take Injury prevention attitudes and beliefs
responsibility for injury prevention are presented in table 4. At postseason, coaches and players held similar beliefs that injur-
ies were preventable (z=−1.76, p=0.08). Coaches and players
continued to believe that muscle, knee and ankle injuries were
most likely preventable. Overall, there were no significant
changes in the strategies believed to prevent these injuries from
Table 1 Baseline characteristics of n=43 coaches and n=385
baseline to postseason (table 3), although significantly more
players from youth soccer in Canada
players than coaches thought that warming up could prevent
Coaches (n=43) Players (n=385) ankle injuries at postseason. There was no effect of randomisa-
Median (range/IQR) Median (range/IQR)
tion group or adherence tertile on the postseason belief that a
Characteristic or frequency (%) or frequency (%)
warm-up could prevent an injury, for coaches or players.
Age group After adjusting for cluster by team, age group (OR=0.1; 95%
U16 25 (58.1) 214 (55.6) CI 0.003 to 1.2), competitive level (OR=0.6; 0.2 to 2.3), years
U18 19* (44.1) 171 (44.4) coaching (OR=1.0; 0.9 to 1.1), years playing (OR=1.1; 0.9
Years coaching experience 10 (0–45/5–15) – to 1.2) and 12-month personal injury history (OR=2.5, 0.5
Have previous soccer playing 30 (69.8) 385 (100.0) to 12.2) were not associated with baseline coach beliefs that
experience injuries are preventable. At postseason, these factors again had
Years of playing experience 8 (0–54/5–25) 10 (1–15/7–11) no effect on the belief that injuries are preventable, nor did ran-
Experienced a personal time 14 (32.6) 194 (50.4) domisation group (OR=0.6; 0.2 to 1.6) or adherence
loss injury playing soccer in (OR=1.0; 0.9 to 1.1).
past 12 months
Age group (OR=0.9; 0.3 to 2.3), competitive level (OR=0.6;
Time loss duration
0.3 to 1.1), years playing (OR=1.0; 0.9 to 1.2) and 12-month
Slight (0–7 days) 3 (21.4) 38 (19.6)
personal injury history (OR=1.6; 0.6 to 4.1) were not asso-
Moderate (8–28 days) 4 (28.6) 73 (37.6)
ciated with player beliefs that injuries are preventable at
Severe (>28 days) 5 (35.7) 59 (30.4)
baseline. These factors had no effect on postseason beliefs
Missing 2 (14.3) 24 (12.4)
that injuries are preventable. Eighty-two injuries were
*One coach was the head coach of a U-14 and a U-16 team (responses are only recorded during the study (details published elsewhere39);
counted once in the remainder of the table).
reporting that an injury during the study period had no effect

McKay CD, et al. Br J Sports Med 2014;48:1281–1286. doi:10.1136/bjsports-2014-093543 3 of 7

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Table 2 Coach and player injury risk beliefs (significant baseline differences between coaches and players indicated by ^ based on 95% CI;
significant postseason differences between coaches and players indicated by § based on 95% CI; significant within-group differences between
baseline and postseason at p<0.01 level indicated by *)
Coach Player
% (95% CI) % (95% CI)

Precomparison–postcomparison
Precomparison–postcomparison (n=29) (n=258)
Whole sample (n=43) Whole sample (n=385)
Baseline Baseline Postseason Baseline Baseline Postseason

Most commonly injured area

Knees and ankles 88.4 (78.8 to 98.0) 89.7 (78.6 to 100) 93.1 (83.9 to 100) 86.2 (82.8 to 89.7) 88.0 (84.0 to 92.0) 89.5 (85.8 to 93.2)
Hamstrings and thighs 4.7 (0 to 11.0) 4.7 (0 to 12.4) 0§ 7.5 (4.9 to 10.1) 5.4 (2.6 to 8.2) 5.0 (2.3 to 7.7)
Other 7.0 (0 to 14.6) 6.9 (0 to 16.1) 6.9 (0 to 16.1) 3.1 (1.4 to 4.8) 2.7 (0.7 to 4.7) 3.1 (1.0 to 5.2)
Injury risk factors
Inadequate warm-up 62.8 (48.4 to 77.3) 69.0 (52.2 to 85.8) 51.7 (33.5 to 69.9)§ 75.8 (71.5 to 80.1) 77.9 (72.8 to 83.0) 78.7 (73.7 to 83.7)
Lack of stretching/flexibility 0^ 0 0§ 57.9 (53.0 to 62.8) 57.4 (51.4 to 63.4) 55.8 (49.7 to 61.9)
Aggression/risk taking 16.3 (5.3 to 27.3)^ 17.2 (3.5 to 30.9) 20.7 (6.0 to 35.5) 43.4 (38.5 to 48.4) 43.8 (37.8 to 49.9) 37.6 (31.7 to 43.5)
Lack of fitness 81.4 (69.8 to 93.0)^ 96.6 (90.0 to 100)* 65.5 (48.2 to 82.8) 43.6 (38.7 to 48.6) 45.0 (38.9 to 51.1) 43.8 (37.8 to 49.9)
Body contact 0^ 0 0§ 29.4 (24.9 to 34.0) 31.4 (25.7 to 37.1) 32.9 (27.2 to 38.6)
Poor muscle strength 0^ 0 0§ 23.1 (18.9 to 27.3) 23.6 (18.4 to 28.8) 26.4 (21.0 to 31.8)
Poor technique 30.2 (16.5 to 43.9)^ 24.1 (8.5 to 39.7) 31.0 (14.2 to 47.8) 10.1 (7.1 to 13.1) 10.1 (6.4 to 13.8) 13.2 (9.1 to 17.3)
Player’s genetics 9.3 (0.6 to 18.0) 6.9 (0 to 16.1) 3.4 (0 to 10.0) 3.1 (1.4 to 4.8) 2.7 (0.7 to 4.7) 5.0 (2.3 to 7.7)

on prevention beliefs (OR=1.1; 0.3 to 4.3), nor did randomisa- coach equally responsible (OR=0.5; 0.2 to 1.4), but players
tion group (OR=0.6; 0.3 to 1.3) or adherence (OR=1.0; were more likely than coaches to think prevention was the
0.9 to 1.1). player’s responsibility at postseason (OR=7.4; 3.0 to 18.2).
At postseason, there was no difference in coach or player atti- Randomisation group and adherence to the 11+ did not affect
tudes towards prevention responsibility. Both groups held the these relationships.

Table 3 The three injuries most commonly believed to be preventable, and prevention strategies suggested by participants (significant baseline
differences between coaches and players indicated by ^ based on 95% CI; significant postseason differences between coaches and players
indicated by § based on 95% CI. No significant within-group differences were found)
Coach Player
% (95% CI) % (95% CI)
Precomparison–postcomparison (n=29) Precomparison–postcomparison (n=258)
Whole sample (n=43) Whole sample (n=385)
Baseline Baseline Postseason Baseline Baseline Postseason

Muscle injury 46.5 (31.6 to 61.4) 41.4 (23.5 to 59.3) 51.7 (33.5 to 69.9) 55.1 (50.1 to 60.1) 55.4 (49.3 to 61.5) 48.8 (42.7 to 54.9)
Stretch 23.3 (10.7 to 35.9) 24.1 (8.5 to 39.7) 27.6 (11.3 to 43.9) 40.5 (35.6 to 45.4) 38.8 (32.9 to 44.8) 36.0 (30.1 to 41.9)
Strengthen 2.3 (0 to 6.8) 3.4 (0 to 10.0) 3.4 (0 to 10.0) 8.1 (5.4 to 10.8) 7.4 (4.2 to 10.6) 9.7 (6.1 to 13.3)
Warm-up 18.6 (7.0 to 30.2) 13.8 (1.3 to 26.4) 10.3 (0 to 21.4) 9.4 (6.5 to 12.3) 9.7 (6.1 to 13.3) 9.3 (5.8 to 12.8)
Equipment 0^ 0 0 4.4 (2.4 to 6.5) 5.8 (3.0 to 8.7) 2.7 (0.7 to 4.7)
Technique 0^ 0 0§ 2.9 (1.2 to 4.6) 3.1 (1.0 to 5.2) 5.4 (2.6 to 8.2)
Other 2.3 (0 to 6.8) 0 10.3 (0 to 21.4) 9.6 (6.7 to 12.5) 11.2 (7.4 to 15.1) 8.5 (5.1 to 11.9)
Knee injury 44.2 (29.4 to 59.0)^ 41.4 (23.5 to 59.3) 51.7 (33.5 to 69.9)§ 18.7 (14.8 to 22.6) 19.0 (14.2 to 23.8) 12.0 (8.0 to 16.0)
Stretch 0^ 0 0§ 11.7 (8.5 to 14.9) 11.6 (7.7 to 15.5) 9.3 (5.8 to 12.8)
Strengthen 27.9 (14.5 to 41.3) 13.8 (1.3 to 26.4) 27.6 (11.3 to 43.9) 15.3 (11.7 to 18.9) 14.3 (10.0 to 18.6) 9.7 (6.1 to 13.3)
Warm-up 0^ 0 0 4.2 (2.2 to 6.2) 4.7 (2.1 to 7.3) 1.2 (0 to 2.5)
Equipment 0 13.8 (1.3 to 26.4) 3.4 (0 to 10.0) 1.3 (0.2 to 2.4) 1.6 (0.1 to 3.1) 0.4 (0 to 1.2)
Technique 9.3 (0.6 to 18.0) 10.3 (0 to 21.4) 6.9 (0 to 16.1) 2.9 (1.2 to 4.6) 3.1 (1.0 to 5.2) 1.2 (0 to 2.5)
Other 7.0 (0 to 14.6) 3.4 (0 to 10.0) 13.8 (1.3 to 26.4) 5.2 (0.2 to 7.4) 4.3 (1.8 to 6.8) 3.1 (1.0 to 5.2)
Ankle injury 25.6 (12.6 to 38.6) 20.7 (6.0 to 35.5) 27.6 (11.3 to 43.9) 28.8 (24.3 to 33.3) 31.4 (25.7 to 37.1) 29.1 (23.6 to 34.6)
Stretch 2.3 (0 to 6.8) ^ 3.4 (0 to 10.0) 6.9 (0 to 16.1) 16.4 (12.7 to 20.1) 18.2 (13.5 to 22.9) 18.2 (13.5 to 22.9)
Strengthen 11.6 (2.0 to 21.2) 13.8 (1.3 to 26.4) 10.3 (0 to 21.4) 7.8 (5.1 to 10.5) 9.7 (6.1 to 13.3) 10.9 (7.1 to 14.7)
Warm-up 0^ 0 0§ 4.2 (2.2 to 6.2) 4.7 (2.1 to 7.3) 4.3 (1.8 to 6.8)
Equipment 0^ 0 0§ 7.0 (4.5 to 9.6) 6.6 (3.6 to 9.6) 7.8 (4.5 to 11.1)
Technique 2.3 (0 to 6.8) 0 6.9 (0 to 16.1) 3.6 (1.7 to 5.5) 3.5 (1.3 to 5.7) 1.9 (0.2 to 3.6)
Other 9.3 (0.6 to 18.0) 3.4 (0 to 10.0) 3.4 (0 to 10.0) 7.0 (4.5 to 9.6) 6.6 (3.6 to 9.6) 6.2 (3.3 to 9.1)
Bold typeface values highlight the proportion believing that these types of injuries are preventable, whereas the non-bold text gives proportions endorsing various prevention strategies
for those types of injuries.
Category ‘other’ includes rest, less aggressive behaviour, fitness.

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Table 4 Beliefs about who is responsible for injury prevention (significant baseline differences between coaches and players indicated by ^
based on 95% CI; significant postseason differences between coaches and players indicated by § based on 95% CI. No significant within-group
differences were found)
Coach Player
% (95% CI) % (95% CI)
Precomparison–postcomparison Precomparison–postcomparison
(n=29) (n=258)
Whole sample (n=43) Whole sample (n=385)
Baseline Baseline Postseason Baseline Baseline Postseason

Who is responsible for injury prevention?

Coach 93.0 (85.4 to 100)^ 93.1 (83.9 to 100) 86.2 (73.7 to 98.8) 74.5 (70.2 to 78.9) 73.3 (67.9 to 78.7) 77.1 (72.0 to 82.2)
Players 90.7 (82.0 to 99.4) 89.7 (78.6 to 100) 69.0 (52.2 to 85.8)§ 95.3 (93.2 to 97.4) 96.1 (93.7 to 98.5) 95.3 (92.7 to 97.9)
Parents 65.1 (50.9 to 79.4)^ 62.1 (44.4 to 79.8) 55.2 (37.1 to 73.3)§ 13.0 (9.6 to 16.4) 12.4 (8.4 to 16.4) 13.6 (9.4 to 17.8)
League or club administration 18.6 (7.0 to 30.2)^ 17.2 (3.5 to 30.9) 20.7 (6.0 to 35.5) 4.7 (2.6 to 6.8) 3.9 (1.5 to 6.3) 5.4 (2.6 to 8.2)
Referee 16.3 (5.3 to 27.3) 13.8 (1.3 to 26.4) 17.2 (3.5 to 30.9)§ 30.6 (26.0 to 35.2) 29.1 (23.6 to 34.6) 39.1 (33.2 to 45.1)
Medical personnel 7.0 (0 to 14.6)^ 10.3 (0 to 21.4) 0§ 36.6 (31.8 to 41.4) 38.0 (32.1 to 43.9) 28.3 (22.8 to 33.8)

Effect of intrinsic factors on adherence of injury risk than their peers at baseline, and that the delivery
For coaches, there was no significant effect of age group strategies for the 11+ were insufficient for translating new
(OR=2.8; 0.4 to 18.5), tier (OR=1.1; 0.2 to 5.3), years of injury risk information.18 27
coaching (OR=1.0; 95% CI 0.9 to 1.1), 12-month personal Players most commonly endorsed stretching as a prevention
injury history (OR=0.7; 0.3 to 1.6) or belief that injuries are strategy. In 1998, a study conducted in English professional
preventable (OR=0.4; 0.1 to 3.7) on being in the upper tertile soccer found that players believed poor flexibility or lack of
of adherence, after adjusting for cluster by team. For players, no stretching to be a risk factor for injury.23 Despite evidence to
effect of age group (OR=0.9; 0.6 to 1.4), tier (OR=1.7; 0.9 to the contrary,43–45 our results suggest that this belief is still preva-
3.2), 12-month personal injury history (OR=0.9; 0.6 to 1.4) or lent in the sport community, but not for coaches. Only a small
belief that injuries are preventable (OR=0.7; 0.3 to 1.9) on proportion of coaches believed stretching would prevent injuries
high adherence was found. at baseline or postseason, indicating that coaches may have
Years of playing experience were negatively associated with accurate beliefs about the value of stretching, but do not effect-
high adherence for coaches (OR=0.93; 0.88 to 0.99) and ively transmit this knowledge to players. This indicates that
players (OR=0.92; 0.85 to 0.98). current delivery strategies for the FIFA 11+ programme do not
ensure that accurate evidence is mobilised to the target audi-
DISCUSSION ence, nor do they effectively address incorrect or outdated pre-
Coaches and players were accurate in their beliefs that knees vention beliefs. This is one potential reason that uptake of the
and ankles are the most commonly injured body parts in soccer programme is low in community sport, and highlights the fact
but, contrary to previous studies, there was no effect of personal that basic knowledge dissemination is insufficient for changing
factors (eg, age group, playing tier, injury history) on their established thought or action patterns.
overall injury prevention beliefs.30 42 Short et al42 examined the Although ‘inadequate warm-up’ was identified as a risk factor
relationship between personal injury history and prevention by coaches and players, very few endorsed warming up as a
beliefs in college soccer, and found that female players who had strategy for reducing injuries. Postseason, significantly more
a history of injury reported greater risk perceptions than their players than coaches thought a poor warm-up was a risk factor,
uninjured peers. Conversely, those without a previous injury but there was no change in the proportions of coaches or
exhibited high confidence in their ability to avoid being players who identified warming up as a prevention technique,
injured.42 Our finding that injury history and reporting an regardless of adherence to the FIFA 11+. The reason for this
injury during the study were unrelated to risk beliefs could discrepancy is unclear, but it highlights the need for improved
reflect age-related differences in prevention self-efficacy or risk understanding of the rationale behind the 11+ in the soccer
perceptions. It could also be the result of social norming within community. It also indicates that, although delivering prevention
the team, whereby the influence of peer or coach beliefs affects programmes through coaches may be the most feasible method
risk perceptions more than one’s own experiences. Both of of reaching a large group of community-based athletes, add-
these possibilities bear further investigation in order to identify itional effort must be made to ensure that coaches are able to
potentially modifiable factors to target with specific intervention accurately translate information, beyond just the content of the
delivery strategies. intervention, to their teams.
Approximately 40–50% of coaches believed that knee injuries The only personal factor associated with adherence to the
could be prevented at baseline and postseason, which is slightly 11+ programme was years of playing experience. It appears
lower than the 62% reported by Orr et al17 in a sample of that the longer coaches and players have been active in soccer,
youth coaches from the same geographical area. However, fewer the less likely they are to perform the 11+ at every training and
than 20% of players believed that knee injuries were preventable match session. This could suggest either that more experienced
at baseline and postseason, which is considerably lower than the individuals think the programme is only suited to novice teams,
46% reported in the Orr et al17 study. Neither coaches nor or that they feel more confident in making their own decisions
players demonstrated a significant improvement in knee injury about the best warm-up to do. FIFA 11+ delivery may therefore
prevention beliefs after exposure to the FIFA 11+ programme. need to be tailored to the audience, and focusing on the poten-
This suggests that the participants in our study were less aware tial performance benefits associated with the programme may

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better appeal to more experienced players and coaches than an
injury prevention message alone.27 46 What are the new findings?

Limitations ▸ There were different gaps in injury knowledge for coaches

Participants were not asked directly about previous exposure to and female youth soccer players.
the FIFA 11+. It is unclear whether experience with the pro- ▸ Injury risk and prevention beliefs did not significantly
gramme would have increased or decreased risk perceptions, but influence adherence to the FIFA 11+ warm-up programme.
it is likely that risk awareness would be higher for these indivi- ▸ Coaches and players with more years of experience were less
duals, leading to an overestimation of baseline knowledge in our likely to adhere to the FIFA 11+ programme.
sample. Furthermore, it is possible that self-report beliefs were
subject to social desirability bias, considering that the question-
naires were completed in a team setting.47 All efforts were made
to ensure that respondents had adequate privacy in which to
complete the questionnaires, but we cannot account for poten-
How might it impact on clinical practice in the near future?
tial under-reporting of risk perception or over-reporting of
intention by athletes wishing to conform to social norms within Delivery strategies for injury prevention programmes must be
the team. As data were collected as part of a larger injury pre- tailored to coach and player audiences to account for different
vention study, there was also a risk of selection bias. Teams may baseline injury risk knowledge and prevention beliefs, as well as
have chosen to participate in the larger study because of greater sport-playing experience.
baseline injury risk perceptions, which might have inflated our
baseline injury risk and prevention belief estimates and, conse-
quently, limited changes between baseline and postseason.
As adherence was collected at the team level, we were Acknowledgements The authors would like to thank all the research assistants,
study therapists and physicians, coaches and players who participated in this project.
also unable to relate personal characteristics to individual adher-
ence. Although it is reasonable to assume that all players in Contributors KS, MR, CFF and CAE were responsible for the conception and
design of the study. KS, MR and CAE coordinated the study and managed all
attendance at a team session participated in the team warm-up aspects, including data collection. CDM conducted all analyses and wrote the first
when it was performed, future studies should account for this draft of the manuscript. All authors had full access to the data and contributed to
objectively. the interpretation of the findings and critical revision of the manuscript.
This study is also limited to adolescent female players in a Funding This study was funded by the FIFA Medical Assessment and Research
competitive Canadian league, and therefore may not be general- Centre (F-MARC), the Alberta Children’s Hospital Research Institute for Child and
isable to boys, younger or older athletes, different levels of play, Maternal Health Professorship in Pediatric Rehabilitation, supported by the Alberta
Children’s Hospital Foundation and Alberta Team Osteoarthritis, supported by
different sports or those in other geographical areas.
Alberta Innovates Health Solutions. CFF was funded from a National Health and
Medical Research Council (of Australia) (NHMRC) Principal Research Fellowship
Future directions (ID:565900). The Sport Injury Prevention Research Centre, the Oslo Sports Trauma
Research Centre, and the Australian Centre for Research into Injury in Sport and its
As adherence to the 11+ does not appear to depend on injury Prevention (ACRSIP) are three of the four International Research Centres for
knowledge or beliefs on the part of either coaches or players, it Prevention of Injury and Protection of Athlete Health supported by the IOC. The
is recommended that studies further examine coach and player Oslo Sports Trauma Research Center has been established at the Norwegian School
motivations for engaging in injury prevention programmes.28 of Sport Sciences through generous grants from the Royal Norwegian Ministry of
Future studies should also correlate player views to those of Culture, the South-Eastern Norway Regional Health Authority, the Norwegian
Olympic Committee & Confederation of Sport and Norsk Tipping AS.
their coaches, to account for the influence of coach beliefs on
player beliefs, and subsequent team behaviour. It will also be Competing interests None.
important to understand the apparent discrepancy between Ethics approval Conjoint Health Research Ethics Board, University of Calgary.
believing that an inadequate warm-up is a risk factor for injury, Provenance and peer review Not commissioned; externally peer reviewed.
but not believing that a warm-up can prevent injury. Moreover,
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