Systematic Development

iPlay Study Systematic Development
You have to review the following paper [provided in PDF file]:
Collard DCM, Chinapaw MJM, van Mechelen W. Verhagen ELM. (2009). Design of the iPlay Study Systematic Development of a Physical Activity Injury Prevention Programme for Primary School Children. Sports Medicine, 39(11): 889-901.
The tasks for you is (to answer the following 2 questions), and to consider how the intervention or program was developed by systematically identifying and appraising the following program elements:
1. setting, target group, objective or desired outcomes, prevention level?
2. how the intervention was developed: strategies, approaches, theories(?), etc
Design of the iPlay Study
Systematic Development of a Physical Activity Injury
Prevention Programme for Primary School Children
Dorine C.M. Collard,1 Mai J.M. Chinapaw,1,2 Willem van Mechelen1,2
and Evert A.L.M. Verhagen1
1 EMGO Institute for Health and Care Research and Department of Public and Occupational
Health, VU University Medical Center, Amsterdam, the Netherlands
2 Research Centre Body@Work TNO VUmc, Amsterdam, the Netherlands
Abstract Health benefits of physical activity in children are well known. However,
a drawback is the risk of physical activity-related injuries. Children are at
particular risk for these injuries, because of a high level of exposure. Because
of the high prevalence of physical activity injuries and the negative short- and
long-term consequences, prevention of these injuries in children is important.
This article describes how we systematically developed a school-based physical
activity injury prevention programme using the intervention mapping
(IM) protocol.
IM describes a process for developing theory- and evidence-based health
promotion programmes. The development can be described in six steps:
(i) perform a needs assessment; (ii) identify programme and performance
objectives; (iii) select methods and strategies; (iv) develop programme;
(v) adopt and implement; and (vi) evaluate.
First, the results of the needs assessment showed the injury problem in
children and the different risk factors for physical activity injuries. Based on
the results of the needs assessment the main focus of the injury prevention
programme was described. Second, the overall programme objective of the
injury prevention programme was defined as reducing the incidence of lower
extremity physical activity injuries. Third, theoretical methods and practical
strategies were selected to accomplish a decrease in injury incidence. The
theoretical methods used were active learning, providing cues and scenariobased
risk information, and active processing of information. The practical
strategy of the injury prevention programme was an 8-month course about
injury prevention to be used in physical education classes in primary schools.
Fourth, programme materials that were used in the injury prevention programme
were developed, including newsletters for children and parents,
posters, exercises to improve motor fitness, and an information website.
Fifth, an implementation plan was designed in order to ensure that the prevention
programme would be implemented, adopted and sustained over time.
Finally, an evaluation plan was designed. The injury prevention programme
is being evaluated in a cluster randomized controlled trial with more than
2200 children from 40 primary schools throughout the Netherlands.
LEADING ARTICLE Sports Med 2009; 39 (11): 889-901
ª 2009 Adis Data Information BV. All rights reserved.
The IM process is a useful process for developing an injury prevention
programme. Based on the steps of the IM we developed an 8-month injury
prevention programme to be used in physical education classes of primary
Regular physical activity (PA) has many health
benefits, for example it lowers the risk of obesity,
coronary heart disease and osteoporosis.[1-3] A
drawback of increased PA levels is the risk of
PA-related injuries. Sports are the leading cause
of injury and hospital emergency room visits in
The high prevalence of PA injuries in children
and the negative short- and long-term consequences
confirm its importance as a health problem.
Although most PA injuries are not life threatening,
the occurrence of PA injury can result in
pain, disability, school absence, absence from
PAs and sometimes in dysfunction in the
short and long term. Therefore, prevention of
PA-related injuries is essential. Emery[6] showed
in a review that injury prevention strategies in
children can reduce the risk of PA injuries.
However, the literature has some limitations and
is based primarily on observational studies for
specific injuries and specific sports.[7] Few studies
on school-based PA injury prevention strategies
have been published. Of these, only one study was
a randomized controlled trial.[8]
Measures to prevent PA injuries should generally
be based on knowledge about the incidence
and severity of the PA injury problem, aetiological
risk factors, and mechanisms contributing to
the risk of sustaining such injuries.[9]
Because a proper school-based PA injury prevention
programme in children does not exist and
evidence on effectiveness is lacking, development
and evaluation of such a programme is necessary.
An injury prevention programme can be developed
using the intervention mapping (IM) protocol.[10,11]
IM describes a process for developing theory- and
evidence-based health promotion programmes,
and involves a systematic process that prescribes
a series of six steps: (i) performing a needs assessment;
(ii) defining suitable programme objectives;
(iii) selecting theory-based intervention
methods and practical strategies; (iv) producing
programme components and materials; (v) designing
an implementation plan; and (vi) designing
an evaluation plan (see figure 1). Collaboration
between the developers, the users of the intervention
and the target population is a basic assumption
in the IM process.[12] This article
describes in detail the development of a PA injury
prevention programme for children by using the
steps of the IM process. Step 6 of the process
descibes in detail how to evaluate the effectiveness
of such a programme.
1. Step 1: Perform a Needs Assessment
Prior to the development of a PA injury prevention
programme for children, the injury problem
and the risk factors for PA injuries in children
should be assessed. In order to gain insight into
the needs of the target population, a focus group
interview with 23 physical education (PE) teachers
from 12 secondary schools was carried out.
1.1 The Injury Problem
Injuries cause children unnecessary suffering
and pain in the short term.[1,8,13] Individuals who
have experienced macro trauma or PA injuries to
joints may be at risk of accelerated development
of (secondary) osteoarthritis in later life.[14]
Moreover, it is suggested that PAinjuries sustained
Step 3: Select theory-based intervention methods and
practical strategies
Step 4: Produce programme components and materials
Step 5: Design an implementation plan
Step 6: Design an evaluation plan
Step 2: Define suitable programme objectives
Step 1: Needs assessment
Fig. 1. Steps of the intervention mapping process.
890 Collard et al.
ª 2009 Adis Data Information BV. All rights reserved. Sports Med 2009; 39 (11)
at a young age have a negative influence on
participation in PAs and sports.[15,16]
Data from the period 2000–2004 revealed that
in theNetherlands 1.5million acute PA injuries are
reported each year and 51% of these injuries are
medically treated. The PA injury incidence in
children aged 0–17 years is 1.3 (95% CI 1.2, 1.4).[17]
The absolute number of PA injuries in the
Netherlands increases for both sexes until the age
of 12 years. Above this age, injuries in boys increase
considerably until the age of 16 years. The
highest number of PA injuries in girls is registered
at 14 years of age. The most frequently injured
body parts are the lower extremities. The ankle is
the most affected part of the body (20%), followed
by the knee (18%).[17]
Although sport participation in children has
increased (children aged 6–11 years: 88% in 1991
to 93% in 2003; children aged 12–19 years: 84% in
1991 to 93% in 2003), membership of sports clubs
has decreased (children aged 6–11 years: 76% in
1991 to 74% in 2003; children aged 12–19 years:
77% in 1991 to 71% in 2003).[18] There are a large
number of children who participate in organized
team sports, but a growing number of children
are attracted to non-organized sports activities
and individual sports. There seems to be a trend
for individualization, and children nowadays are
attracted to sports other than traditional sports
in a sport club.[19] The literature shows that most
PA injuries occur during non-organized sports
activities and leisure time.[20-22]
Data from a nationwide survey in the
Netherlands showed that school absence occurs
in 7% of the children who sustained a sports injury,
and the mean duration of school missed by
these children was 8 days. This means that 0.02%
of the total population who visit school and
participate in sports are absent from school one
or more days. With a mean duration of 8 days,
the total school absence due to sports injuries can
be calculated at 794 000 days a year. In addition,
22%of the people who sustained a PA injury were
also absent from PAs.[17]
The economic consequences of PA injuries in
children are not known, but direct medical costs,
for examplemedical treatments as a result of all PA
injuries, were estimated at h170 and indirect medical
costs, for example work or school absence, were
estimated at h420 million (year of costing 2003).[23]
Risk factors for PA injuries are factors that
increase the potential risk for injury and include
extrinsic risk factors (i.e. weather, field conditions)
and intrinsic risk factors (i.e. age, conditioning).
Identification of risk factors can be used as a
leading guide for preventive measures. However,
it is clear that injuries are caused mostly by a combination
of factors. Table I shows the most important
risk factors for PA injuries in children.[5]
Based on these data, the aim our injury prevention
programme should be to prevent lower
extremity PA injuries in school children. A prevention
programme to prevent PA injuries embedded
in PE classes in schools will reach all the
children who are physically active – not only
children in sport clubs. PA injuries are defined as
injuries occurring during organized sports activities,
leisure time activities and PE class.
Table I. Risk factors for physical activity injuries in children[5]
Extrinsic risk factors Intrinsic risk factors
non-modifiable potentially modifiable non-modifiable potentially modifiable
Sport played (contact/no contact) Rules Previous injury (Aerobic) fitness level
Level of play (recreational/elite) Playing time Age Pre-participation in sport-specific training
Position played Playing surface (type/condition) Sex Flexibility
Weather Equipment (protective/footwear) Strength
Time of season/time of day Joint stability
Psychological/social factors
Developing a Physical Activity Injury Prevention Programme 891
ª 2009 Adis Data Information BV. All rights reserved. Sports Med 2009; 39 (11)
1.2 Focus Group Interviews
In order to gain insight into the needs of the
target population and in order to be able to design
a feasible intervention programme, focus
group interviews were held. Five individual interviews
and two focus group interviews were performed
with 23 PE teachers from 12 secondary
schools. In the Netherlands, children go to primary
school until the age of 12 years, followed by
attendance at secondary school.
The interviewed secondary school PE teachers
generally agreed there is a great diversity in physical
fitness and motor performance in children in
the first grade of secondary schools. Their common
opinion was that these interindividual differences
are an important contributing factor to
PA injuries in children. Asking the interviewed
PE teachers about the causes of the noted diversity
in physical fitness and motor control, and
particularly about possible solutions, they argued
that an intervention programme should focus on
primary school children. In primary schools, children
receive regular PE classes. Unfortunately,
these regular PE classes are not always supervised
by certified PE teachers (due to economic reasons,
the child’s regular teacher often provides
the PE classes). However, the regular teachers
usually do not incorporate injury prevention aspects
in their PE classes; as general injury prevention
lessons are not given in primary schools,
it is likely that a preventive intervention in this
setting can lead to maximum improvement.
In addition, the PE teachers in secondary
schools said they were hesitant and not motivated
to incorporate our preventive intervention in their
PE classes, because they already incorporated
their own injury prevention in their PE classes.
Because the PE teachers in secondary schools
argued that the intervention programme should
focus on primary schools since injury prevention
lessons are already given in secondary schools, a
shift from secondary school children to primary
school children was made.
From the focus group interviews with the PE
teachers we also learned that, in general, the PE
teachers were rarely confronted with injuries, and
they were unaware of a sports injury problem
among their pupils. From the interviews it became
clear that raising injury knowledge in children,
teachers and parents should be an important objective
for our intervention programme.
2. Step 2: Define Suitable Programme
This step provides the foundation for the programme
by specifying who and what will change
as a result of the intervention. The overall objective
of our intervention programme was to reduce
the incidence of lower extremity PA injuries. In
order to achieve this overall objective, several
risk-reduction behavioural and interpersonal environment
‘sub-objectives’ were defined that focus
on children, parents and PE teachers. The
underlying assumption of the risk-reduction behavioural
sub-objectives is that if an intervention
reduces the prevalence of risk factors, it will reduce
the prevalence of PA injuries. Furthermore,
the presence or absence of support from important
others (e.g. parents, PE teachers) within
the individual’s immediate interpersonal environment
may have an influence on the performance
of the injury-preventing behaviour.[24] The subobjectives
used in our preventive measure are:
(i) children take fewer injury-related risks;
(ii) parents create a safe PA environment for their
children outside PE classes; (iii) and teachers
include injury prevention into their usual teaching
Performance objectives were defined on the
basis of the programme objectives and describe
what the participants in this programme need to
do to perform the desired injury-preventing behaviour.
The performance objectives for each
programme objective are presented in table II.
3. Step 3: Select Theory-Based
Intervention Methods and
Practical Strategies
The third step of the IM process is the selection
of theory-based intervention methods and practical
strategies to effect changes in the health behaviour
of individuals, and to change organizational
and societal factors to alter the environment.
892 Collard et al.
ª 2009 Adis Data Information BV. All rights reserved. Sports Med 2009; 39 (11)
A ‘method’ can be described as a theoretically derived
technique used to influence (determinants
of) injury-preventing behaviour, and a ‘strategy’
as a practical way of organizing and delivering
the intervention method.[12,25]
3.1 Theory-Based Intervention Methods
Preventive measures should target one or more
of the risk factors mentioned earlier (table I). A
potentially modifiable risk factor for PA injuries
in children is wearing appropriate protective
equipment and footwear during PAs. To decrease
this risk factor, injury-preventing behaviour
should be addressed. Injury-preventing behaviour
is an indirect causal factor for PA injuries.[26]
Therefore, improving this behaviour could be a
method to decrease PA injury incidence and PA
injury severity. To change injury-preventing behaviour,
knowledge of determinants of behaviour
is necessary.[27] We applied the attitude, social
influence and self-efficacy (ASE) model for
behaviour change. The ASE model is based on
the theory of planned behaviour[28] and the social
learning theory.[29] This model[30,31] postulates
that intention, the most proximal determinant of
behaviour, is determined by three conceptually
independent constructs: attitude, social influence
and self-efficacy.

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