Sports Medicine

https://doi.org/10.1007/s40279-018-0953-x

REVIEW ARTICLE

Context Matters: Revisiting the First Step of the ‘Sequence

of Prevention’ of Sports Injuries
Caroline Bolling1 · Willem van Mechelen1,2,3,4 · H. Roeline Pasman1 · Evert Verhagen1,2

© The Author(s) 2018

Abstract
It is possible to prevent sports injuries. Unfortunately, the demonstrated efficacy and effectiveness of injury prevention
approaches are not translated into lasting real-world effects. Contemporary views in sports medicine and injury prevention
suggest that sports injuries are ‘complex’ phenomena. If the problem we aim to prevent is complex, then the first step in the
‘sequence of prevention’ that defines the ‘injury problem’ already needs to have considered this. The purpose of this paper
is to revisit the first step of the ‘sequence of prevention’, and to explore new perspectives that acknowledge the complex-
ity of the sports injury problem. First, this paper provides a retrospective of the ‘sequence of prevention’, acknowledging
contemporary views on sports injuries and their prevention. Thereafter, from the perspective of the socioecological model,
we demonstrate the need for taking into account the complex nature of sports injuries in the first step. Finally, we propose
an alternative approach to explore and understand injury context through qualitative research methods. A better understand-
ing of the injury problem in context will guide more context-sensitive studies, thus providing a new perspective for sports
injury prevention research.

Key Points

Contemporary views in sports medicine highlight the

complexity of sports injuries and their prevention.
The widely used ‘sequence of prevention’ needs to take
the complexity into account, starting with the first step
‘describing sports injury problem’.
Introducing qualitative research approaches as a means
to include complexity of the sport injuries in the problem
* H. Roeline Pasman description provides ways to more comprehensively
hrw.pasman@vumc.nl understand the sports injury context.
1
Amsterdam Collaboration for Health and Safety in Sports,
Department of Public and Occupational Health, Amsterdam
Public Health Research Institute, VU University Medical
Center, Van der Boechorststraat 7, 1081 BT Amsterdam, 1 Introduction
The Netherlands
2
UCT/MRC Research Unit for Exercise Science and Sports Since the ‘sequence of prevention’ of sports injuries [1] was
Medicine (ESSM), Department of Human Biology, Faculty published, many studies have shown that under ideal (i.e.
of Health Sciences, University of Cape Town, Cape Town,
controlled) and pragmatic (i.e. real-world) conditions, it is
South Africa
3
possible to reduce injury incidence, injury severity and the
School of Public Health, Physiotherapy and Population
costs associated with sports-related injuries [2]. The out-
Sciences, University College Dublin, Dublin, Ireland
4
come of controlled trials is referred to as ‘efficacy’, whereas
School of Human Movement and Nutrition Sciences,
the outcome of pragmatic trials is defined as ‘effectiveness’.
Faculty of Health and Behavioural Sciences, University
of Queensland, Brisbane, QLD, Australia Unfortunately, the demonstrated efficacy and effectiveness

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 C. Bolling et al.

results are not translated into a lasting meaningful effect and emphasizing the need to consider context-specific
in the real world [3–6]. Consequently, implementation has research questions, and highlighting the need for a greater
become a major question, i.e. ‘how to translate evidence emphasis on qualitative methods being used in sport injury
into practice?’. prevention research.
To overcome this implementation gap in our field, Finch
has proposed the “Translating Research into Injury Preven-
tion Practice” (TRIPP) framework [4]. TRIPP adds two addi- 2 Contemporary Sports Medicine
tional steps to the ‘sequence of prevention’: (1) the need is Complex
for understanding the implementation context (personal,
environmental, societal and sports delivery factors); and (2) As already mentioned, contemporary views in sports medi-
the evaluation of the implementation process of preventive cine support the notion that sports injuries are ‘complex’
measures [4]. The need for an evaluation of the implemen- and propose an ecological and dynamic systems approach
tation process highlights our limited understanding of the towards injury prevention interventions. Bittencourt et al. [9]
sports context as a potential driver of preventive behaviour proposed a framework that challenges the current reduction-
[7]. Thus, knowledge is required about the setting, the cul- ist approach to sports injury aetiology, presenting ‘complex-
ture, and the infrastructure related to sports injuries, which ity’ as an alternative paradigm to understand the occurrence
could be so-called contextual determinants of the injury of sports injury. Following the same reasoning, Bekker and
prevention process. Clark [10] suggested analysing injury through the lenses of
In the Oxford Dictionary, ‘context’ is defined as “the complexity, acknowledging the importance of understanding
interrelated conditions in which something exists or occurs” the influence of context in sports injury research. Finally,
[8]. Drawing a parallel with sports injury, this implies that Hulme and Finch [11] advocated the need to introduce a
for the same injury, the ‘injury problem’ can differ, based on complementary systems paradigm for a better understanding
differences in context, e.g. between a circus artist, an elite of the process of preventing sports injuries.
athlete, or a professional dancer. A dancer can deny or not If the sports injury problem is acknowledged to be com-
report an ankle sprain and still perform because she is afraid plex throughout the steps of the ‘sequence of prevention’,
to lose her position as a soloist, whereas a basketball player, as the three views outlined above propose, then the first
with the same type of ankle sprain, will normally be out of step that defines the ‘injury problem’ needs to have already
training for a week or more, but will probably continue play- considered this complexity and the context of sports injury
ing if the injury happens before an important final game in before moving to the next steps. After all, if one starts with
the play-offs. However, if we look at the injury from just a no or limited knowledge about the context of a sports injury,
biomedical perspective, it is the same injury, with equal tis- this will lead to the development of context-free preventive
sue damage and clinical prognosis. Yet, when the context is solutions.
considered, these injuries present different problems, which As an analogy, let us say we are using our efficacy knowl-
will consequently require different preventive (and curative) edge to put our resources into building a Formula 1 car. The
solutions. The development of such solutions should then Formula 1 car performs perfectly under controlled condi-
logically be based on the athlete and his or her context prior tions, such as a pristine Formula 1 track. However, if our
to the implementation of any solution, and should take into Formula 1 car then had to be used in everyday conditions,
consideration the demands, needs, possibilities and motiva- we would realize that we would need to drive it on country
tion of the athlete. backroads. If we had known the conditions it had to drive on
These contextual aspects of sports injury should already at the outset, we would have built a 4 × 4 instead, i.e. a much
be described and analysed as part of the problem description, slower alternative, but better aligned to the context in which
i.e. in the first step of the ‘sequence of prevention’. Conse- it needs to operate. Now to make our efforts worthwhile,
quently, this paper revisits the first step of the ‘sequence of within our current research paradigm we try to modify the
prevention’, introducing context as part of the sports injury road for it to fit our Formula 1 car, rather than going back to
problem definition, and proposes a new approach to explore the design table to create a car that actually fits the context.
the context in which injuries occur. This is also exactly what happens in sports injury preven-
First, we explain how the importance of context has led to tion research.
the introduction of complexity in sports injury prevention. Efficacious interventions are developed and tested under
Thereafter, this conceptual paper provides a retrospective controlled conditions, after which we attempt to change the
on the ‘sequence of prevention’ in light of the complexity users’ behaviour to adopt our ‘ideal’ intervention. Verhagen
paradigm. From there, we demonstrate the need to take into [12] has argued that this is not the right approach and stated
account context complexity at the beginning of the injury that injury prevention efforts need to be built around athlete
prevention process. We conclude this review by proposing behaviours to be effective. Injury prevention should focus on
Sports Injuries in Context

‘what works for whom, when, where and why’ [10]. Conse- risk factors, which are proximate to the injury event and are
quently, there is a need to know and understand more about individual-related [14]. On the other hand, upstream risk fac-
the behavioural aspects related to injury occurrence. tors are factors largely outside the control of the individual,
for instance psychosocial factors, which are less targeted in
sports injury research [15–17].
3 Revisiting the Steps of the ‘Sequence The multifactorial and dynamic nature of injuries has
of Prevention’ been recognized by distinguishing the intrinsic and extrin-
sic risk factors that lead to injury, yet in a sequential linear
3.1 Step 1: Describe the Sports Injury Problem way [18]. More recently, Bittencourt et al. [9] introduced the
concept of a web of determinants (i.e. risk factors), which
In the first step, the sports injury problem is described implies a complex and dynamic systems approach, in a
by the magnitude of the problem and its severity (Fig. 1). multiple-levels network. Following this web of determinants
The problem ‘injury’ is typically measured by epidemio- model, each context will present multiple pathways that may
logical measures and quantified in epidemiological studies. lead to comparable injury outcomes.
Prevalence, incidence, severity, injury profiles, time loss,
and costs have all been well-described in a wide variety of 3.3 Step 3: Introduce Preventive Measures
sports, and stratified by age, sex, participation level, sports,
experience, etc. [2]. The third step is to introduce measures that are likely to
reduce the future risk and/or severity of sports injuries.
3.2 Step 2: Describe Injury Aetiology These measures should be based on the risk factors and the
mechanism(s) identified in the second step. Consequently,
Historically, based on traditional biomedical and patho- the following interventions should target well-described,
physiological aetiology, the cause–effect paradigm has been modifiable risk factors. In this third step, emphasis is typi-
applied widely in sports injury research, focusing on finding cally placed on controlling or changing the environment
the independent effect of a risk factor on injury outcome. (i.e. external risk factors) and/or on modifying intrinsic
Knowledge about risk factors is mainly established through person-related risk factors. Because behaviour is supposed
biomechanical, biomedical and epidemiological research to modify risk factors and injury mechanisms, behaviour is
[6]. Many biomechanical and neuromuscular factors have seen as an important component of the injury prevention
been identified as risk factors for the occurrence of lower- intervention [6]. Adopting preventive interventions aimed at
limb injuries in many sports [13]. However, most risk factor reducing sports injury risk can be regarded as health behav-
studies assume sequential linearity to explain the occur- iour. However, from a public health perspective, the study
rence of sports injury and deal mainly with downstream of any health behaviour in isolation from the broader social
and environmental context is incomplete and will lead to
disappointing results when experiments targeting behav-
iour change are transferred into the ‘real world’ [19]. For
example, interventions to prevent overweight or to increase
physical activity are more successful when multilevel, con-
textual, socioecological factors (e.g. cultural background and
environmental changes) are understood and considered when
translated into practice [20].
Verhagen et al. [6] have already pointed out the need to
address behaviour and to identify determinants of sports
behaviour when attempting to prevent sports injuries.
McGlashan and Finch [17] reviewed and analysed the use
of behavioural and social sciences theories and models in
research, and found that most sports injury prevention stud-
ies applied individual-level (intrapersonal/interpersonal)
theories. Their review showed that organizational- and
community-level theories have been used rarely. The latter
types of theories tend to assume that context is inherent to
preventive behaviour and consider more than the individual.
Fig. 1  The ‘sequence of prevention’ of sports injuries (adapted from More recently, Vriend et al. [21] reviewed intervention strat-
van Mechelen [1], with permission) egies for sports injury prevention and concluded that most of
 C. Bolling et al.

the interventions had targeted the individual. Based on the of a sports injury prevention intervention and not just in the
limited understanding of behaviour as a key determinant of implementation phase.
effective injury prevention applied in sports injury research,
McGlashan and Finch [17] have recommended that future
sports injury prevention studies should consider the com- 4 You Cannot Expect Good Wine from Bad
plexity of sports behaviours. Grapes

In a recent editorial, Bekker and Clark [10] questioned the

3.4 Step 4: Evaluation of Introduced Measures
‘sequence of prevention’ if the only question is ‘does the
intervention work or not?’. They argued that the ‘sequence
Given that interventions have been developed, the fourth
of prevention’ is simplistic, considering the complexity of
step aims to ensure that measures actually ‘work’. Many
the sports injury. However, the sequence provides, just as
interventions have been tested in a controlled and relatively
any framework, merely a way to operationalize the research
context-free environment and have shown to be able to pre-
process (Fig. 1). In a production process, the feedstock, i.e.
vent injuries. Subsequent studies have studied proven effi-
the raw material, will determine the final product. When
cacious interventions in more practical (i.e. less controlled)
thinking about the four steps of the ‘sequence of prevention’,
environments and have evaluated effectiveness and cost
it is important to recognize that the feedstock (i.e. the first
effectiveness [2]. However, research has also demonstrated
step) is the problem description and is highly important in
that many other factors affect intervention effectiveness,
regard to the processes and outcomes of subsequent steps.
including factors such as intervention adherence, attitudes
Over the years, the content of the steps of the ‘sequence
and beliefs [17]. This notion has led to the development of
of prevention’ has been revisited and new context-driven
the sequence of steps in the TRIPP framework [4], which tar-
perspectives have been added. Within the second step, new
gets the implementation process of efficacious interventions.
insights have been proposed which consider aetiology as
consisting of a ‘web of determinants’ that should be under-
3.5 Additional Steps to Support Implementation stood from the perspective of a ‘complex systems approach’
[9–11]. In the third step, some studies have shown the impor-
The implementation process has also been evaluated to tance of incorporating socioecological theory to understand
obtain a better understanding of the limited effect of inter- behaviour [17, 26, 27]. In the fourth step, and subsequent
ventions in effectiveness studies [22]. To this end, the RE- implementation steps, recent studies have highlighted the
AIM framework [23] has been applied to injury prevention importance of taking contextual determinants into account
interventions to evaluate reach, effectiveness, adoption, when the success of an intervention and its implementa-
implementation and maintenance of such interventions. tion are evaluated [24]. However, the first step, in which we
This RE-AIM framework provides ‘contextual’ parameters describe the problem, seems to still be performed with a
to evaluate the intervention and its implementation. context-free narrow focus on the injury (Fig. 2).
A systematic review evaluating 52 published injury
prevention trials using the RE-AIM framework identified
that major gaps in the implementation of preventive meas- 5 A Fresh Start for the ‘Sequence
ures can be identified in the adoption and maintenance of of Prevention’
interventions [24]. These two aspects of the implementa-
tion process relate to the behaviours of end users, who need The injury will involve an athlete who can be character-
to adopt the measures and support their maintenance. The ized by many individual features as well as multiple extra-
review stipulated the importance of the recognition of multi- individual factors that are associated with injury risk, e.g.
ple stakeholders within a sports system who are relevant for the level of performance in a particular sport, which has a
effective implementation of intervention measures, including specific culture, is regulated by a specific association and
players, coaches, staff and administrators. takes place in a particular socioeconomic class in a specific
A review of the use of the RE-AIM framework in public country (Fig. 3).
health research [25] also indicated an increased awareness A recommended approach would be to consider the
of the importance of context and provides support for ask- injured athlete being in the centre of a socioecological
ing questions such as ‘which complex intervention for what model, an approach already presented for medical inter-
type of complex patients, delivered by what type of staff, ventions and health policies [28]. Bronfenbrenner and Ceci
will be most cost-effective, under which conditions, and for [29] postulated that to understand an individual’s develop-
what outcomes?”. Thus, contextual factors should be taken ment and behaviour, the entire ecological system in which
into consideration earlier in the process of the development this individual acts needs to be taken into account. The
Sports Injuries in Context

Fig. 2  In the past 25 years, the ‘sequence of prevention’ of sports the outset. Contemporary views demand the ‘sequence of prevention’
injuries has been mostly applied to produce context-free evidence, i.e. to be context-driven, which will provide a more comprehensive view
describing the problem and following the steps in controlled environ- of the injury problem and effective solutions
ments that did not consider the context as part of the problem from

Fig. 3  A socioecological view

of sports injuries that includes
context at multiple levels, i.e.
individual, sociocultural and
environmental

recent paper by Ekstrand et al. is, for instance, a good 6 Exploring the Context
example of how coach leadership style, as part of an eco-
logical system, is related to soccer injuries [30]. Some 6.1 New Questions
authors have already presented a socioecological model
as a framework for analysing the preventive behaviours There is a need to solve problems in sports medicine prac-
in sports injury causation [17, 26, 27, 31]. If the injured tice, and, in order to do that, the injury problem needs
athlete is placed at centre stage in the viewpoint, the soci- to be addressed in context. It is necessary to understand
oecological model can help to understand the dynamic the athlete’s context and how this context affects injury,
interrelations between, among others, physical, biological, how the athlete perceives injury, and how the athlete deals
ecological, technical, economic and social aspects.
 C. Bolling et al.

with prevention. Instead of asking whether an intervention view might provide a better understanding of injury occur-
works for a specific problem, new questions should ask rence and a more comprehensive way to describe the ‘sports
how context impacts a problem [32]. injury’ problem.
Public health has been challenged by similar questions Qualitative research is more than just ‘another method’. It
for many years (and still is). For example, ‘condom use’ is a requires a different approach to the problem, instead of the
simple preventive measure that, despite its proven efficacy, positivistic approach that attempts to find a unique truth that
is not always current practice. Some studies have tried to can be generalized, i.e. the most common approach in quantita-
understand why teenagers refrain from using a condom even tive research [46]. Qualitative research accepts a more natu-
though they acknowledge the risk of disease and unintended ralistic approach, recognizing multiple realities and seeking to
pregnancies [33]. The answers were found by qualitative understand and interpret relationships between different reali-
research methods, showing the relevance of contextual fac- ties. The different perspectives that surround the sports injury
tors that play an important role in behaviour, in this case arise from different beliefs and assumptions, which shape the
partner influence and social acceptance, for example [33, way that a coach, athlete or health provider will behave.
34]. To further illustrate challenges in the context of sport
injury prevention, Bahr et al. [3] conducted the Nordic 7 Conclusions
Hamstring Survey. It was found that teams do not adopt and
implement an exercise programme with a well-documented After the first step of the ‘sequence of prevention’, armed
effect on both injury and re-injury risk, but continue to use with a broad view of the injury problem and a deeper under-
exercises with no or limited supporting evidence [3]. Such standing of the context, the next steps will evolve further into
outcomes underline the necessity of new research methods context-sensitive research evidence, giving better grounds
to better understand the contextual determinants of a specific for injury prevention research. To explore sports injury ques-
prevention process. tions, researchers need to understand and explore the context
in which injuries occur. By applying qualitative methods in
6.2 New Research Method Approaches Needed sport injury prevention research, we will be able to gain an
in-depth understanding of the context in which injuries occur.
New context-specific questions on the ‘how’ and ‘why’ need Instead of translating science to practice, we need to take con-
to be posed in sports injury prevention research in order text into account in order to speak a common language. Once
to provide better understanding of the injury in its context this has been done, tailored interventions can be designed,
[35]. Given the complex nature of sports injuries, there is implemented and tested in the real world, rather than trying to
a need for a greater depth of understanding of the problem transfer customised programmes based on proven efficacious
than the current knowledge attained mostly from quantita- interventions into the real world with limited effectiveness.
tive methodologies. Embracing complexity requires changes
in the way that we build evidence, for instance by incor- Author Contributions Caroline Bolling developed the reasoning for
this paper and drafted the first version. Evert Verhagen, Willem van
porating qualitative methods in our studies. This idea to Mechelen and Roeline Pasman contributed intellectually and provided
incorporate qualitative methods is part of building evidence feedback on various drafts.
about complex phenomenon [10, 36]. Qualitative methods
can address gaps in our understanding of a process and can Compliance with Ethical Standards
provide a contextual perspective on the problem, yielding
insights not previously studied [37]. Qualitative methods Funding Caroline Bolling is a PhD candidate supported by Conselho
are becoming increasingly prevalent in medical research, Nacional de Desenvolvimento Científico e Tecnológico 1—CNPq, Bra-
zil (Grant Number 202242/2015-3). No other sources of funding were
however qualitative research has been limited in the sport used to assist in the preparation of this article.
injury prevention area [38–43]. Qualitative methods provide
ways for researchers to explore and explain contexts, ena- Conflict of interest Caroline Bolling, Willem van Mechelen, Roeline
bling a more comprehensive understanding of many aspects Pasman and Evert Verhagen declare that they have no conflicts of in-
of health [44]. The context shapes evidence and qualitative terest relevant to the content of this review.
research can highlight aspects that would usually fall outside
the purview of traditional evidence [45]. Open Access This article is distributed under the terms of the Crea-
tive Commons Attribution 4.0 International License (http://creat​iveco​
Many pieces of the puzzle are missing because of the lim- mmons​.org/licen​ses/by/4.0/), which permits unrestricted use, distribu-
ited understanding of the complexity of the sport context in tion, and reproduction in any medium, provided you give appropriate
which an injury occurs. Prior to measurement and quantifica- credit to the original author(s) and the source, provide a link to the
tion of the problem, qualitative methods can explore this con- Creative Commons license, and indicate if changes were made.
text and describe in-depth insights, based on the perspectives
of athletes, coaches and health providers [38, 41–43]. Their
Sports Injuries in Context

References identifying studies applying the Haddon Matrix. Sports Med.

2017;174:1–17.
22. Finch CF, Donaldson A. A sports setting matrix for under-
1. van Mechelen W, Hlobil H, Kemper HC. Incidence, severity, aeti-
standing the implementation context for community sport. Br J
ology and prevention of sports injuries. A review of concepts.
Sports Med. 2010;44:973–8.
Sports Med. 1992;14:82–99.
23. Glasgow RE, Vogt TM, Boles SM. Evaluating the public health
2. Klügl M, Shrier I, McBain K, et al. The prevention of sport
impact of health promotion interventions: the RE-AIM frame-
injury: an analysis of 12 000 published manuscripts. Clin J
work. Am J Public Health. 1999;89:1322–7.
Sport Med. 2010;20:407–12.
24. O’Brien J, Finch CF. The implementation of musculoskeletal
3. Bahr R, Thorborg K, Ekstrand J. Evidence-based hamstring
injury-prevention exercise programmes in team ball sports: a sys-
injury prevention is not adopted by the majority of Champions
tematic review employing the RE-AIM framework. Sports Med.
League or Norwegian Premier League football teams: the Nor-
2014;44:1305–18.
dic Hamstring survey. Br J Sports Med. 2015;49:1466–71.
25. Gaglio B, Shoup JA, Glasgow RE. The RE-AIM framework:
4. Finch CF. A new framework for research leading to sports injury
a systematic review of use over time. Am J Public Health.
prevention. J Sci Med Sport. 2006;9:3–9 (discussion 10).
2013;103:e38–46.
5. Verhagen E, Voogt N, Bruinsma A, et al. A knowledge transfer
26. Eime R, Owen N, Finch CF. Protective eyewear promotion: apply-
scheme to bridge the gap between science and practice: an inte-
ing principles of behaviour change in the design of a squash injury
gration of existing research frameworks into a tool for practice.
prevention programme. Sports Med. 2004;34:629–38.
Br J Sports Med. 2014;48:698–701.
27. Hanson D, Hanson J, Vardon P, et al. The injury iceberg: an eco-
6. Verhagen E, van Stralen MM, van Mechelen W. Behav-
logical approach to planning sustainable community safety inter-
iour, the key factor for sports injury prevention. Sports Med.
ventions. Health Promot J Austr. 2005;16:5–10.
2010;40:899–906.
28. Sterman JD. Learning from evidence in a complex world. Am J
7. Finch CF. No longer lost in translation: the art and science of
Public Health. 2006;96:505–14.
sports injury prevention implementation research. Br J Sports
29. Bronfenbrenner U, Ceci SJ. Nature-nurture reconceptualized in
Med. 2011;45:1253–7.
developmental perspective: a bioecological model. Psychol Rev.
8. Stevenson A. Oxford dictionary of english. Oxford: Oxford Uni-
1994;101:568–86.
versity Press; 2010.
30. Ekstrand J, Lundqvist D, Lagerbäck L, et al. Is there a correlation
9. Bittencourt NFN, Meeuwisse WH, Mendonça LD, et al. Com-
between coaches’ leadership styles and injuries in elite football
plex systems approach for sports injuries: moving from risk fac-
teams? A study of 36 elite teams in 17 countries. Br J Sports Med.
tor identification to injury pattern recognition: narrative review
2018;52(8):527–31.
and new concept. Br J Sports Med. 2016;50:1309–14.
31. Jacobsson J, Bergin D, Timpka T, et al. Injuries in youth track and
10. Bekker S, Clark AM. Bringing complexity to sports injury pre-
field are perceived to have multiple-level causes that call for eco-
vention research: from simplification to explanation. Br J Sports
logical (holistic-developmental) interventions: a national sporting
Med. 2016;50:1489–90.
community perceptions and experiences. Scand J Med Sci Sports.
11. Hulme A, Finch CF. From monocausality to systems thinking:
2017;48:287–8.
a complementary and alternative conceptual approach for better
32. Rutter H, Savona N, Glonti K, et al. The need for a com-
understanding the development and prevention of sports injury.
plex systems model of evidence for public health. Lancet.
Inj Epidemiol. 2015;2:31.
2017;390(10112):2602–4.
12. Verhagen E. If athletes will not adopt preventive measures,
33. Baxter S, Blank L, Guillaume L, et al. Views regarding the use
effective measures must adopt athletes. Curr Sports Med Rep.
of contraception amongst young people in the UK: a systematic
2012;11:7–8.
review and thematic synthesis. Eur J Contracept Reprod Health
13. Murphy DF, Connolly DAJ, Beynnon BD. Risk factors for lower
Care. 2011;16:149–60.
extremity injury: a review of the literature. Br J Sports Med.
34. Brown S, Guthrie K. Why don’t teenagers use contraception? A
2003;37:13–29.
qualitative interview study. Eur J Contracept Reprod Health Care.
14. Pearce N, Merletti F. Complexity, simplicity, and epidemiology.
2010;15:197–204.
Int J Epidemiol. 2006;35:515–9.
35. Verhagen E, Bolling C. We dare to ask new questions. Are we
15. Ivarsson A, Johnson U, Andersen MB, et al. Psychosocial fac-
also brave enough to change our approaches? Transl. Sports Med.
tors and sport injuries: meta-analyses for prediction and preven-
2018;1:54–5.
tion. Sports Med. 2017;47(2):353–65.
36. Trochim WM, Cabrera DA, Milstein B, et al. Practical challenges
16. Wiese-Bjornstal DM. Psychology and socioculture affect injury
of systems thinking and modeling in public health. Am J Public
risk, response, and recovery in high-intensity athletes: a con-
Health. 2006;96:538–46.
sensus statement. Scand J Med Sci Sport. 2010;20:103–11.
37. Jack SM. Utility of qualitative research findings in evidence-based
17. McGlashan AJ, Finch CF. The extent to which behavioural and
public health practice. Public Health Nurs. 2006;23:277–83.
social sciences theories and models are used in sport injury
38. McGlashan AJ. Enhancing the integration of specialised exercise
prevention research. Sports Med. 2010;40:841–58.
training into coach practices to prevent lower-limb injury: using
18. Meeuwisse WH, Tyreman H, Hagel B, et al. A dynamic model
theory and exploring coaches’ salient beliefs (PhD). Ballarat: Fed-
of etiology in sport injury: the recursive nature of risk and cau-
eration University Australia; 2015.
sation. Clin J Sport Med. 2007;17:215–9.
39. McGlashan A, Verrinder G, Verhagen E. Working towards more
19. Glass TA, McAtee MJ. Behavioral science at the crossroads in
effective implementation, dissemination and scale-up of lower-
public health: extending horizons, envisioning the future. Soc
limb injury-prevention programs: Insights from community
Sci Med. 2006;62:1650–71.
Australian Football coaches. Int J Environ Res Public Health.
20. Heath GW, Parra DC, Sarmiento OL, et al. Evidence-based
2018;15(2):351.
intervention in physical activity: lessons from around the world.
40. McGlashan A. Coach perceptions of risk factors associated with
Lancet. 2012;380:272–81.
lower limb injuries. J Sci Med Sport. 2017;20:e7.
21. Vriend I, Gouttebarge V, Finch CF, et al. Intervention strate-
gies used in sport injury prevention studies: a systematic review
 C. Bolling et al.

41. Fagher K, Forsberg A, Jacobsson J, et al. Paralympic athletes’ per- 44. Creswell J. Research design: qualitative, quantitative and mixed
ceptions of their experiences of sports-related injuries, risk factors methods approaches. Nurse Res. 2004;12:82–3.
and preventive possibilities. Eur J Sport Sci. 2016;16(8):1240–9. 45. Upshur RE, VanDenKerkhof EG, Goel V. Meaning and measure-
42. van Wilgen CP, Verhagen E. A qualitative study on overuse ment: an inclusive model of evidence in health care. J Eval Clin
injuries: the beliefs of athletes and coaches. J Sci Med Sport. Pract. 2001;7:91–6.
2012;15:116–21. 46. Kuper A, Reeves S, Levinson W. An introduction to reading and
43. Caron JG, Bloom GA, Bennie A. Canadian high school coaches’ appraising qualitative research. BMJ. 2008;337:a288.
experiences, insights, and perceived roles with sport-related con-
cussions. Int Sport Coach J. 2015;2(3):285–97.