If Athletes Will Not Adopt Preventive Measures, Effective Measures Must Adopt Athletes

Safety in sports and physical activity is an important prerequisite for maintenance of a healthy physically active lifestyle, as well as continuing participation in sports. For this reason, prevention, reduction, and control of sports injuries are important goals, not only for clinicians and researchers but also for society as a whole. In 1992, van Mechelen et al. (5) postulated that measures to prevent sports injuries do not stand by themselves; they form part of what they called the sequence of prevention. Over the past decade, the sequence of prevention has been adopted widely in sports injury research and arguably is the most extensively used theoretical framework in our field of research. There is no doubt that its use in sports injury research has led to a wide array of preventive measures for various injuries within different sports. However, recently, debate has arisen about the “true” effect of thus attained preventive measures in a real-life sports setting. As stated by Finch (3), only research outcomes that are adopted by athletes, coaches, and other intermediaries actually will prevent injuries. The question then is, “how do we make sure research outcomes are adopted and effectively used by stakeholders?” In an attempt to answer this question, Finch (3) introduced the TRIPP (translating research into injury prevention practice) framework as an expansion of the original sequence of prevention. The TRIPP approach aims at a better understanding of the implementation context for injury prevention and stresses the importance of understanding both behavioral inputs and outputs in relation to sports injury prevention. In explaining the rationale behind the TRIPP framework, Finch uses a scene from the movie “Lost in Translation.” In this scene, a Japanese director explains vividly and in full detail how he wants the actor to play a certain scene. The problem is that the actor is English and does not understand a word of Japanese. There is a translator present, but in the translation from Japanese to English, the detailed instructions are reduced to a message with no target, context, desired behavior, or expected outcome. As a result, the actor has no clue as to how to perform. Finch then argues that proper translation is a key factor for successful implementation. This metaphor certainly hits the spot as to where we stand in the implementation of sports injury preventive measures, in more ways than Finch might have intended originally. Most importantly, I would argue that the problem is not so much the translation but the message to begin with. In the aforementioned example, both the sender (director) and the receiver (actor) are professionals. The only barrier is their language. The director can be very specific and detailed, as he knows that the actor can process this information and act accordingly. In sports injury prevention, however, this is not always the case. In sports injury prevention, we are not dealing with a sender and receiver who have the same basic knowledge, skills, and motivation in relation to the content of the message. Knowledge and skills are needed to ensure proper translation of research evidence into practical messages, for instance, through training of (sports) medical professionals who may act as translators of scientific evidence for their patients. Motivation, however, is something completely different. Motivation, defined as the general desire or willingness of someone to do something, is inherent to a specific stakeholder. Green and Kreuter (4) have encapsulated this idea in their “lenses of health,” by which they explained that professionals have a greater interest in objective health indicators, whereas athletes are more interested in subjective health indicators. I would argue that this subtle difference is exactly where we stand now, facing an implementation gap. We researchers come up with perfectly designed preventive measures and programs that have been studied scientifically using methodologically sound approaches. This produces the most efficacious preventive measures from a biomedical, biomechanical, and/or physiological perspective. We then expect that these proven preventive measures will be adopted if the determinants and influences of sports safety behaviors are understood and targeted in implementation strategies. In a sense, we try to translate objective research outcomes into the subjective expectations of the end user; we may try to convince an athlete who has rehabilitated from an ankle sprain that an 8-wk neuromuscular training protocol consisting of three 30-min training sessions per week will reduce his or her ankle sprain recurrence risk. It is a very efficacious intervention but with very low compliance (7). What we basically are attempting to do is to change the player’s preventive behavior to adopt our proven preventive measure. However, it is known from studies on lifestyle interventions that altering an individual’s behavior in such a way is very difficult, if not impossible. If Mohammed will not come to the mountain, the mountain must come to Mohammed. I previously argued for a novel approach in sports injury prevention along the lines of this saying (6). We stated that if one truly wants to prevent sports injuries in a real-life situation, a broader research focus is needed from the isolated injury and its underlying factors to the athlete as a whole. In other words, we need to develop injury-preventive measures around the athlete, not the injury. In this development, we already need to take into account the demands, wishes, needs, possibilities, and motivation of the athlete. One very promising framework in constructing such acceptable and evidence-based intervention programs is the Intervention Mapping (IM) protocol (1). IM captures the process of the development of a health promotion program in a series of six consecutive steps. IM maps the path from recognition of a need or problem to the identification of a behavioral solution and provides the tools to do so in a multidisciplinary manner. The strength of IM lies therein that the end users and others involved with the intervention program are part of the development process. While originally designed for health promotion programs, the IM protocol can be used easily for injury prevention programs as well (2). Following the IM protocol, before a start is made with the actual development of the intervention program, the health problem needs to be assessed. This assessment should include related behaviors, environmental conditions, and their associated determinants for the at-risk populations. This initial problem definition encompasses two components: (A) a scientific, epidemiological, behavioral, and social perspective of an at-risk group or community and its problems and (B) an effort to “get to know” or begin to understand the character of the community, its members, and its strengths. This starting point is more than a description of a health problem as commonly applied in sports medicine research; i.e., ankle sprains are the most common injuries. It is a description of a health problem, its impact on quality of life, behavioral and environmental causes, and determinants of behavior and environmental causes. If an injury problem is approached in this way, the resulting intervention program is built around the acting behaviors. Thereby, the translational process that is being put forward as the key to implementation success is already part of intervention development. The author declares no conflict of interest and does not have any financial disclosures.