Grass-Root Coaches Knowledge, Understanding, Attitude And Confidence to Deliver Injury Prevention Training in Youth Soccer: a Comparison of Coaches in Three EU Countries

Abstract

Purpose

It is well recognised that injury prevention training can reduce injury incidence, however current coach education pathways do not provide grass-root coaches with the knowledge and confidence to deliver such training to youth players. The aim of this study was to explore differences in knowledge, understanding, attitude and confidence to deliver such injury prevention training in three European countries.

Methods

A total of 269 grass-root soccer coaches from 3 European countries (Czech Republic, UK, Spain) were recruited for this study. A validated questionnaire exploring knowledge, understanding, attitude towards and confidence to deliver youth injury prevention training was completed prior to a 2 h workshop on injury prevention training. Differences between countries was examined using Bayesian factors to quantify the evidence for and against the hypothesis of independence (H0) by assuming a Poisson sampling scheme (as there was no a priori restriction on any cell count, nor on the grand total) (BF10 Poisson).

Results

Current knowledge, attitude and confidence to deliver injury prevention training to youth players was poor across all three European countries. Relatively few coaches were currently using injury prevention training in their coaching sessions (23%). There were some country specific differences for attitude towards injury prevention training and confidence to deliver injury training, with Spanish coaches reporting a more positive attitude and confidence to deliver such training. Significantly fewer coaches in the UK were using injury prevention training compared to coaches in Spain and the Czech Republic.

Conclusion

As coaches identified a need for coach education and few were delivering injury prevention training, there is a clear need to embed and implement this programme into the grassroots coaching framework of sports governing bodies to improve adoption, implementation and maintenance.

Introduction

It is well recognised that children aged between 12–18 year-of-age are at the greatest risk of sustaining a serious non-contact injury that has both short and long-term health consequences [22, 23]. Recent data suggest that the risk of paediatric sport injury is high and constitutes a significant public health burden [15]. A number of recent economic cost analysis studies indicate that neuromuscular training reduces injury burden and economic and social costs associated with injury in youth sport [15, 21]. Indeed, the study of Rössler et al. [21] reported that implementation of the FIFA11 + Kids programme reduced healthcare costs by 51% compared to a traditional warm up providing compelling evidence for its widespread implementation.

Coaches play a major role in encouraging and ensuring that participants of their teams adopt appropriate safe practices [25]. However, the extent to which coaches undertake this role is influenced by their knowledge, beliefs and attitude towards injury prevention programmes. Injury prevention programmes need to be age, sex and maturation specific with clear progressions as a child grows and matures. There is currently a need to develop such materials that are suitable for grass-root coaches. It is well recognised that coaches who uptake and adhere to such prevention programmes can reduce injury incidence in their youth athletes by up to 80% and one randomised control trial saw a 89% reduction in injury rates during just 1 season of the adoption of an injury prevention programme [24]. Alongside growing support for injury prevention programmes efficacy, evidence of significant challenges to implementing these programmes has emerged [18]. Thus, despite the well-recognised benefits of adopting an injury prevention programme, uptake, adherence and compliance are often poor [18]. This is concerning as high compliance has been associated with greater injury reductions. Coaches have been identified as important adoption targets for injury prevention programmes in amateur soccer but recent studies have identified low levels of amateur coaches using such programmes. Linked to these data are significant knowledge gaps amongst community level coaches regarding injury prevention programmes [17, 20].

The few studies that have aimed to explore coach knowledge and current use of injury prevention programmes has identified that knowledge and use is generally low [6, 16, 26]. Mawson et al. [16] recently surveyed 101 Canadian youth soccer coaches and reported that injury prevention training was used by only 25% of coaches with those coaches who had attended more coaching courses more likely to use such training. Most coaches (84%) who were not using injury prevention training indicated that if they were more aware of the effectiveness of such training then they would be more likely to use it. The authors concluded that barriers to use of such training was a lack of communication and education between the sporting organisations and the coaches [16]. In a nationwide study of use of injury prevention training in amateur soccer the number of teams using such training has not changed over 7 years (2008, 21.7%; 2015, 21.9%). However, awareness of such training does not always translate into practice as a study exploring awareness and use of the FIFA 11+ in 1223 German amateur level football coaches [26]. In this study 43% of coaches were aware of the FIFA 11+ with only 31% using the programme. Children involved in talent development pathways often have access to sports science and medicine support at their clubs, however the majority of children participating in sport do so at the grassroot level and thus it is the local grassroots coach that holds the responsibility for the welfare of the youth players they coach.

Currently coach education and CPD for registered coaches across European nations are managed and delivered by the National associations/federations. National strategies will develop the generic awards and CPD for coaches who are then normally delivered by the regional associations, especially in football, and this is the case in Czech Republic, the UK and Spain. Currently there are CPD modules that focus on the youth soccer player but there are no CPD workshops or materials on youth injury prevention programmes linked to player well-being/welfare. Grass-root/community coaches do not have such support mechanisms even though player well-being forms a large part of their remit as the coach. The aim of this study was to compare the knowledge, attitude towards and confidence to deliver injury prevention training in grassroot soccer coaches in three European countries. We hypothesized that there would be no significant between country differences in knowledge, attitude towards and confidence to deliver injury prevention training in grass-root coaches due to the similar coach education pathways in each country and that none of the countries provide specific CPD workshops or materials on youth injury prevention.

Methods

Two hundred and sixty-nine grass root coaches from three European countries (Czech Republic, n = 111; UK, n = 68; Spain, n = 90) were invited (via regional football associations/federations) to attend a free 2 h workshop on injury prevention in youth soccer. The total sample consisted of 238 (88%) male and 31 (12%) female coaches. Inclusion criteria were: (1) Participants needed to be aged 18 years or above; (2) were a licensed member of their countries National Football Association; (3) coached a youth football team; (4) were not coaching a semi/professional team. Coaches’ knowledge of, attitude towards and confidence to deliver youth injury prevention as part of their coaching was explored at the start of the workshop via a questionnaire. Some questions required a yes/no answer and others were based on a 5-point likert-scale. This paper-based survey was administered by the lead researchers to all course participants at the beginning of the workshop before any discussion regarding youth injury prevention.

Questionnaire Development

The questionnaires were compiled following the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework [8] after a review of the wider coach education literature, and in collaboration with the three European partners of the project to ensure that any country specific issues were addressed. The framework has been most commonly applied as an evaluation tool but has broader application as a planning tool and as a method to review intervention studies [4].

The scales, items and concepts deployed were derived and adapted, in part, from the survey employed by O’Brien and Finch [18] exploring the perceptions of the deliverers of injury prevention training in youth soccer. Following pilot testing, the final set of questions were developed and agreed upon through consultation between the authors, and football association/federation representatives. The first part of each questionnaire elicited demographic and background information from coaches including level of coaching qualification, sex, age group coached, number of years coaching. The second part of the questionnaire assessed 10 questions related to knowledge of injury prevention programmes, attitude towards injury prevention and confidence to deliver injury prevention. Perceived barriers and facilitators towards delivering such training was also explored. These were assessed both in terms of the relative level of importance attributed to each item (rated on a 5-point scale ranging from Strongly Agree (5) to Strongly Disagree (1). The questionnaires were administered in the respective languages of the participating countries (questionnaires can be found in the supplementary materials).

Statistical Analysis

Statistical analyses were performed using JASP (Amsterdam, Netherland) software version 0.10. For all analysis the null hypothesis assumed no significant difference would be observed between countries for knowledge, attitude and confidence to deliver injury prevention training. For each of the possible responses of the survey questions, the true and expected (supposing a priori that the null hypothesis were true [H0 = variables are independent]) frequency of cases coded were calculated (both grouped and separately for country) through a R (rows = possible responses of the questions) x C (columns = country [Czech Republic, United Kingdom and Spain) Bayesian contingency table.

The Bayesian factor described by Gunel and Dickey [9] (henceforth GD74) was used to quantify the evidence for and against the hypothesis of independence (H0) in each of the survey questions and with regards to the three countries that took part in this study assuming a Poisson sampling scheme (as there was no a priori restriction on any cell count, nor on the grand total) (BF10 Poisson). The expected frequency in each cell consists of the fully observed cases in the cell and the expected number of the partially observed cases that fall in the cell.

Despite the inherently continuous nature of the Bayes factor as a measure of evidential strength, Jeffreys [12] and Lee and Wagenmakers [14]  proposed to categorize Bayes factors in the following discrete categories:   < 1/100 = extreme evidence for H0, from 1/100 to < 1/30 = very strong evidence for H0, from 1/30 to < 1/10 = strong evidence for H0, from 1/10 to < 1/3 = moderate evidence for H0, from 1/3 to < 1 anecdotical evidence for H0, from 1 to 3 = anecdotical evidence for H1, from > 3 to 10 = moderate evidence for H1, from > 10 to 30 = strong evidence for H1, from > 30 to 100 = very strong evidence for H1, > 100 extreme evidence for H1.

Results

Only 16% of coaches had heard of any type of injury prevention programme but 84% of the coaches acknowledged that they thought it was possible to prevent injuries in youth soccer with such training. Subsequently, all coaches (100%) acknowledged that injury prevention training was important for youth players and that coach education was needed for them to confidently deliver such training, but only 40% of coaches stated that they had a positive attitude towards injury prevention training. Only 59% of coaches consider that youth players are at high risk of injury to the lower limb and only the same amount consider that lower limb injuries in youth players can affect their current quality of life. Knowledge regarding injury prevention training was low with only 19% of coaches acknowledging any knowledge regarding this type of training. Only 25% of coaches felt confident to delivery injury prevention training with 23% of coaches currently delivering any form of injury prevention training into their coaching. 76% of coaches acknowledge that injury prevention training needs to be progressive and fun for grass-root players. 25% of coaches were currently implementing some injury prevention training into their coaching sessions with youth footballers. Statistical analysis exploring country specific differences regarding use of injury prevention programmes, knowledge of injury prevention programmes, attitude towards such programmes and confidence to deliver youth injury prevention training can be found in the following section.

Do You Use an Injury Prevention Programme Currently in Your Sessions?

Table 1 reports that a relatively high percentage of the European grass-root coaches surveyed (74.8%) were not delivering any form of injury prevention training into their coaching. Furthermore, the statistical analysis conducted showed that there is extreme evidence (BF10 Poisson = 185.4) in favor of the alternative hypothesis so that a relationship of dependency between the responses to the question 1 indicates that country differences exist. The proportion of coaches from the Czech Republic that are currently delivering any form of injury prevention training (33.9%) is higher than that observed in Spanish coaches (25.2%) and much higher than the proportion of coaches from the United Kingdom (8.9%) (Fig. 1).

Table 1 Do you use an injury prevention programme currently in your sessions? 
Fig. 1
figure1

Coaches' use of injury prevention programmes by country

Question 2: My Knowledge of Injury Prevention Issues Before the Workshop Was

Table 2 indicates that current knowledge regarding injury prevention for youth sport is very low with only 19% of European grass-root coaches surveyed reporting good (16%) or very good (3%) knowledge. Furthermore, the statistical analysis indicated that there is anecdotical evidence (BF10 Poisson = 0.116) in favor of the alternative hypothesis so that a relationship of dependency between the responses to the question 2 for country does not exist. For example, the proportion of coaches reporting good or very good knowledge in the Czech Republic (16.3%) Spain (22.2%) and United Kingdom (17.4%) were similar (Fig. 2).

Table 2 My knowledge of injury prevention issues before the workshop was
Fig. 2
figure2

Coaches' knowledge of injury prevention by country

Question 3: My Attitude Toward Injury Prevention Before the Workshop Was

Table 3 reports that a just over a third of European grass-root coaches surveyed (39.8%) had a positive attitude towards injury prevention training. Statistical analysis indicated that there is extreme evidence (BF10 Poisson = 1329.9) in favor of the alternative hypothesis so that a relationship of dependency between the responses to the question 3 and country does exist. In this case Spanish coaches had a better attitude towards injury prevention training than Czech (26.4%) and UK (37.7%) coaches (Fig. 3).

Table 3 My attitude toward injury prevention before the workshop was
Fig. 3
figure3

Coaches' attitude towards injury prevention by country

Question 4: How Would You Rate Your Confidence to Deliver an Injury Prevention Programme?

Table 4 indicates that about a quarter of European grass-root coaches surveyed (24.8%) were confident to deliver injury prevention training into their coaching. Statistical analysis showed that there is strong evidence (BF10 Poisson = 26.8) in favor of the alternative hypothesis indicating a relationship of dependency between the responses to the question 4 and country exists. Spanish coaches (37.3%) were more confident than both Czech (20%) and UK (15.9) coaches to deliver injury prevention training to youth athletes (Fig. 4).

Table 4 My confidence to deliver injury prevention before the workshop was
Fig. 4
figure4

Coaches' confidence to deliver injury prevention by country

Discussion

The findings of the current study indicate that grassroot soccer coaches knowledge and confidence to deliver injury prevention training to youth players is generally poor irrespective of the European country where the coach education has been delivered. There is a slightly better attitude towards this type of training with around half of all coaches indicating a positive attitude towards injury prevention training. This is supported by the fact that all coaches (100%) felt that this type of training was important for preventing injuries in youth players. Despite this only a small proportion (23%) were currently including injury prevention training into their coaching practice. This finding is in agreement with the previous work of Frank et al. [5] who reported high levels of acknowledgement that injury prevention training could enhance athletic performance and reduce injury risk in youth athletes but despite behavioural intention to include such activities into their coaching, adoption and implementation levels are low. This is surprising when it is well recognised from recent systematic reviews that neuromuscular intervention programmes are effective in reducing injury rates in youth sport [3, 11, 21]. However, as Emery and colleague point out there is an ongoing concern regarding the uptake and maintenance of such programmes, which may be attributed to coach knowledge, understanding and attitude towards such interventions. In the current study the number of coaches currently using some form of injury prevention programme in their coaching (25%) is in line with previous studies on youth football coaches, which range from 22% to 31% [7, 16, 18, 19, 26].

Given that all of the coaches (100%) felt that injury prevention is important for youth athletes it seems somewhat strange that current football coach education in the 3 European countries do not provide coaches with the knowledge and confidence to deliver such training. Others have also identified that coaches acknowledge the importance for such programmes (86%) without subsequent compliance/implementation [6]. In part this is probably due to the high demands placed on grass root coaches despite their often “volunteer” status and the need to upskill in a wide range of areas that includes tactical/technical components as well as issues surrounding safeguarding physical and psychological development. It has also been suggested that low frequency of training sessions [10] and coach knowledge [13] possibly influence the implementation of such programmes. Given the limited time on coach education courses it may be necessary for governing bodies to include this type of training as a compulsory CPD activity to add to the welfare agenda of the youth soccer player.

Overall knowledge regarding injury prevention training was low (19%) and there were no differences in knowledge between countries. This most likely relates to the previous comment regarding the lack of time to deliver such knowledge to coaches within the limited timeframe that grass-root coach education awards contain (approximately 45 h in UK, 455 h in Spain and 80 h in Czech Republic for a level 1 coaching award). In a recent study by Mawson et al. [16] with Canadian soccer coaches, one-third of coaches acknowledged that risk of injury and prevention had been discussed in their coaching courses, but this study included coaches across all levels. It is likely that a lack of knowledge surrounding the benefits of injury prevention training, alongside a lack of knowledge regarding types of injury prevention programmes (only 16% had knowledge of any injury prevention programmes in the current study) probably contributes to the lack of translation of intent into practice. This has previously been identified in the study of Frank et al. [5] where poor knowledge translated into a lack of confidence to deliver such training and was thus seen as a major barrier to adoption, implementation and maintenance. It is therefore important that coaching courses introduce injury risk and prevention at the grassroot level to provide coaches with the knowledge and confidence to deliver such programmes.

Despite a lack of knowledge regarding injury prevention training nearly 40% of coaches had a positive attitude towards including this type of training into their coaching. Most of the other coaches had a neutral attitude towards such training (rather than a negative attitude) which is probably reflective of a lack of knowledge surrounding the subject area. Country specific differences were observed regarding attitude to such training with Spanish coaches demonstrating a more positive attitude than coaches in the UK and Czech Republic (58% vs. 36% and 26% respectively). This difference may be reflective of the nature of grassroot coach set ups in the respective countries with the UK having more ‘volunteer’ coaches at these levels and Spanish coaches being more aligned to professional clubs at these levels. Indeed, coaches in Spanish grassroot clubs are usually qualified to UEFA B level (level 1 coaching award totalling 455 h) as opposed to those level 1 coaches in the UK (43 h total qualification time) and Czech republic (80 h total qualification time). This greater alignment to professional environments and coach education time, where knowledge around injury prevention is likely greater, may account in part for this country specific difference.

Overall only a quarter of coaches (25%) felt confident to deliver injury prevention training but there were significant differences between countries with Spanish coaches more confident than coaches in the UK and Czech Republic. This again may be reflective of the structural alignment of grassroot coaches to more professional environments in Spain and a more “volunteer” status in the UK and Czech Republic. Only 14% of coaches in the UK felt confident to include injury prevention training into their coaching and this reflects the lack of knowledge provided by the current coach education pathway. Our findings, indicating that a quarter of coaches were confident to deliver such training, is lower than that reported in a small number of female youth coaches [5]. Frank et al. [5] reported that 41% of female coaches felt comfortable in leading an injury prevention element in their coaching session. This perceived behavioural control has been shown to be important for adoption and implementation as heightened levels of intent are needed for behavioural change to take place. Previous studies have indicated that behavioural intent is the strongest predictor of behavioural change [1]. In Spain although over a third of coaches (37%) felt confident to deliver injury prevention training only about a fifth (22%) were delivering such training. These data are in line with previous studies that have also reported higher levels of confidence or intent to deliver compared to those implementing such training [26]. For example, Frank et al. [5] reported that 88% of coaches demonstrated intent to include injury prevention into their coaching but only 53% actually implement the training. Further investigation is required to elucidate why coaches with the confidence to deliver are not implementing this into their coaching practice. A specific study in Spain exploring barriers and facilitators to implementation, using mixed methods approaches is therefore warranted.

There were significantly more coaches in both Spain and the Czech Republic using injury prevention programmes than coaches in the UK (22% and 37% vs. 9%). The low levels of coach implementation in all countries is of concern but is especially worrying in the UK. Interestingly in the Czech republic 37% of coaches were using injury prevention training but only 16% felt they had the knowledge to do so and only 19% felt confident enough to deliver such training. It is somewhat concerning that such training is being delivered without the knowledge to ensure that training is age, maturation and sex appropriate and that progressions are appropriate. Further coach education in the Czech Republic is required to make sure that implementation, under the RE-AIM framework is underpinned by robust knowledge that is paediatric specific in order to safeguard players who are in the care of coaches during training and matches.

The findings of the current study reinforce the need that a key focus of must be placed upon coach education to ensure effective adoption and implementation via developing knowledge, changing attitudes and behaviours, especially in those coaches who are early in their coaching careers. There is clearly a need to embed movement competency training in level 1 and 2 of the coach education pathway, with appropriate resources to support knowledge gain that can be achieved via the dedicated workshops. This will aid grassroot coaches in adopting, implementing and maintaining movement competency training to promote lifelong habits in the children they coach. It is important to note that recent research has identified that positive attitudes and beliefs, and intent to implement, do not necessarily translate to coaching practice [5] without role modelling from both organisations and at club level. It has also been recognised in elite sporting environments that the leadership style of the coach in terms of attitude towards injury prevention in vital in the success of recuing injury incidence [2]. Studies are needed that explore the effectiveness of such coach education programmes to increase knowledge and change attitudes towards such training so that it is adopted, implemented correctly and importantly maintained. It is also important to also explore potential perceived and actual facilitators and barriers to adoption, implementation and maintenance.

Conclusion

As all coaches identified a need for coach education and few were delivering injury prevention training, there is a clear need to embed and implement this programme into the grassroots coaching framework of sports governing bodies. These findings reinforce that the current coach education programmes do not provide grass-root coaches across the 3 European countries with the knowledge and confidence to deliver injury prevention training. In those countries where there is already some knowledge around injury prevention training but little implementation, federations and governing bodies need to reassess the delivery of such knowledge as this is not translating into changing practice.

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Acknowledgement

This study was funded by a European Union research grant: Erasmus + 2016-2602. “The European Commission support for the production of this publication does not constitute an endorsement of the contents which reflects the views only of the authors, and the Commission cannot be held responsi-ble for any use which may be made of the information contained therein.”.

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De Ste Croix, M., Ayala, F., Sanchez, S.H. et al. Grass-Root Coaches Knowledge, Understanding, Attitude And Confidence to Deliver Injury Prevention Training in Youth Soccer: a Comparison of Coaches in Three EU Countries. J. of SCI. IN SPORT AND EXERCISE 2, 367–374 (2020). https://doi.org/10.1007/s42978-020-00075-0

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Keywords

  • Youth
  • Injury prevention training
  • Coach education
  • Movement competency