Developing a Physical Activity Injury Prevention Programme

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.
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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
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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.
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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.
To change injury-preventing behaviour and
finally decrease injury incidence, our programme
tries to improve attitude, social influence, selfefficacy
and intention towards wearing appropriate
protective equipment and footwear during
organized PAs, leisure time activities and PE
classes (see figure 2).
In addition, a second potentially modifiable
risk factor for PA injuries in children is dimensions
of motor fitness (e.g. flexibility, strength
and balance/proprioception). Motor fitness and
sport-specific skills have an impact on sports injuries.[
32] There is some evidence that improving
certain dimensions of motor fitness can decrease
PA injuries. However, this evidence is found in
sport-specific studies[33-38] (see figure 2).
Theoretical methods are general techniques
for influencing changes in determinants of behaviour.
In our programme the following methods
will be used: active learning, providing cues and
scenario-based risk information, and active processing
of information.[24] The related theories for
the adopted methods are the persuasion communication
matrix, elaboration likelihood, social
cognitive theory, theories of information processing,
and a precaution adoption process model.[24]
3.2 Practical Strategies
The next step is to translate the methods into
practical strategies that can be used in a preventive
measure. Knowledge is a basis for many
different determinants of behaviour, but giving
Table II. Performance objectives for the four different programme objectives
Programme objective 1:
children will take fewer injuryrelated
Programme objective 2:
parents will create a safe physical activity
environment outside PE classes
Programme objective 3:
PE teachers will include injury
prevention into their usual teaching
1 Children learn the
consequences of an injury
Parents learn the consequences of an injury PE teachers learn the consequences
of an injury
2 Children learn which risk
factors cause injuries
Parents learn which risk factors cause injuries PE teachers learn which risk factors
cause injuries
3 Children gain insight into their
own injury risk behaviour
Parents gain insight into the injury risks during the
child’s leisure time physical activities
PE teachers gain insight into the pupils’
risk behaviour
4 Children form strategies to
reduce their injury risk
Parents form strategies to reduce the injury risk
during the child’s leisure time physical activities
PE teachers form strategies to reduce
the pupils’ risk behaviour
5 Parents gain insight into the child’s risk behaviour
6 Parents form strategies to reduce the child’s risk
PE = physical education.
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children information will not lead directly to
behavioural change. However, behavioural determinants
like attitude are based partly on knowledge.[
39] The practical strategy that is used to
deliver information in order to increase attitude,
social influence, self-efficacy and motor fitness is
an 8-month course about injury prevention. The
communication channels are a course manual for
teachers, newsletters for children and parents,
posters for children, an exercise programme
during PE lessons for children, and an interactive
website. The newsletters can be made especially
for children or parents, and the willingness to
receive a newsletter is usually good.[24] In addition,
posters can be effective in calling attention
to a campaign and they provide continuous exposure
to the children.[24] Table III gives an
overview of the determinants, methods, theories
and strategies to reach the programme objectives.
3.3 Interpersonal Environment
Changing determinants of behaviour is almost
always embedded in one or more environmental
levels. A child participating in PAs is in an environment
with parents and PE teachers, therefore
parents and PE teachers should also be involved
in the intervention programme.[24] Parents
are very important in creating a safe PA environment
outside PE classes. They should encourage
their children to play safe,[40] and they
are important as role models for their children.
The influence of parental rules and pressure has
been found to have a strong effect on the use of
protective equipment.[41-43]
PE teachers are very important in creating a
safe PA environment during PE classes. In order
to prevent injuries in PE classes it is important
that teachers include injury prevention into their
usual teaching routine. If PE teachers include
injury prevention into their teaching routines,
they will teach children how to prevent injuries
during PAs, not only during PE classes, but also
outside school.
4. Step 4: Produce Programme
Components and Materials
The task in this step of the IM process is to
translate methods and practical strategies into
programme components and materials. Our injury
prevention programme as a whole is not
Decrease PA injury incidence rates
Decrease severity of PA injuries
Intention Injury-preventing behaviour
The degree to which
performance of injurypreventing
behaviour is
positively or negatively
Motor fitness
Dimensions of motor
fitness are strength,
flexibility, speed, power
and balance/coordination
Social influence
Consists of three
– Subjective norms
– Social support
– Pressure and modelling
The subjective probability
that a person is capable of
executing injury-preventing
Fig. 2. A conceptual model of injury prevention. PA= physical activity.
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ª 2009 Adis Data Information BV. All rights reserved. Sports Med 2009; 39 (11)
specified for any specific type of sport. It addresses
the most common injuries and preventive
measures in general and includes the programme
components and materials outlined below.
4.1 Newsletters
Monthly newsletters are produced for both
children and parents. The aim of the newsletters
is to increase knowledge and awareness about
injury prevention. The monthly newsletters consist
of information about injury prevention, selfevaluation
tests and puzzles on a specific topic.
By providing a monthly newsletter, new information
will be given each month in a motivational
way. It is believed that this will remind all involved
each month of the task of preventing PA
4.2 Posters
Eight different posters (A1 size, i.e. 594· 840mm)
show the highlights of the content of the newsletters.
The posters contain important and clear
messages about injury prevention and are very
colourful and have humorous cartoon images in
order to make the posters attractive to children.
They are displayed in the classroom, so that the
children are able to see the posters continuously.
4.3 Exercises to Improve Motor Fitness
A short training circuit is performed at the
beginning and the end of each PE class, twice a
week. This circuit consists of exercises aimed at
the improvement of motor fitness (i.e. strength,
speed, balance/coordination and flexibility). The
exercises are developed on the basis of exercises
from ‘active childhood-healthy life’,[44] exercises
from ‘Basisdocument Bewegingsonderwijs’,[45]
and exercises from a programme to prevent lower
limb injuries in youth sports.[37] Table IV gives
examples of the exercises that are done during the
PE classes.
4.4 Website
The website ( contains general
information about injury prevention for
children, parents and PE teachers, who can view
the newsletters online, and children can check
their solutions to the newsletter puzzles. Additionally,
various instruction videos and photos
are displayed to illustrate for PE teachers how to
teach the exercises.
4.5 Pretesting and Revising
Pilot testing of programme strategies and materials
with intended implementers and recipients
is an important part of step 4.
4.5.1 Pretesting the 8-Month Course
Teachers and children of six primary schools
were informed about the programme in full detail.
Teachers were asked for their comments on
the topics and timing of the different modules of
the 8-month course via a focus group interview.
With the exception of a few minor comments, all
interviewed primary school teachers were positive
about the programme and believed the programme
to be feasible and effective. Children
Table III. Theoretical methods and practical strategies to reach programme objective
Determinants Methods Theory Strategies
Attitude Active learning Persuasion communication
Newsletter delivered to children and parents to
improve knowledge
Social influence Cues Elaboration likelihood Posters exposed to children in the classroom to
improve knowledge
Self-efficacy Scenario-based risk
Social cognitive theory Course manual for teachers
Motor fitness Active processing of
Theories of information
Short circuit training to improve motor fitness
during physical education classes
Precaution adoption process
Website accessible for children, parents and
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responded in a comparable way and were very
enthusiastic about the monthly newsletters and
posters. Although the programme also targets
parents, for practical reasons they were not asked
for their comments about the 8-month course.
However, the positive response of teachers and
children led us to believe that the programme will
be widely accepted in its current form.
4.5.2 Pretesting Exercise Programme
The exercise programme to improve motor
fitness was pretested in two different primary
schools, involving three PE teachers. Teachers
were asked specifically for their comments on the
feasibility of the exercises, the level of intensity,
the degree of difficulty of the exercises and the
clarity of the manual. Some exercises were perceived
as too difficult or taking too much time.
Additionally, the teachers advised delivery of the
exercises in a more competitive and playful way.
Exercises were adapted as suggested by the PE
teachers. The teacher’s manual was considered to
be very clear.
5. Step 5: Design an Implementation Plan
This step focuses on the design of an implementation
plan, in order to ensure that an
injury prevention programme will be implemented,
adopted and sustained over time.
The intervention programme is a ‘ready to use’
preventive measure so it can be implemented directly
in PE lessons, if proven effective. The
Royal Association of Teachers of Physical Education
(KVLO) and the Academy for PE Teachers’
Education will then play an important role
in the implementation. The KVLO controls the
standards and continuity of physical education in
the Netherlands, and has a wide array of implementation
channels. Thereby, the KVLO will
be an important channel through which the preventive
programme can be implemented not only
by today’s PE teachers, but also by the PE teachers
of the future. Another channel that plays an
important role in successful implementation is
the academic school where PE teachers are educated.
The KVLO and the Academy for PE
Teachers’ Education have been involved in the
study from the very beginning and have participated
in the IM process. By using IM, the programme
was tailored to the wishes of the end
users. In doing so, the practical and logistical
issues of implementation have been minimized.
6. Step 6: Design an Evaluation Plan
Through effect and process evaluation, IM
planners can determine whether decisions were
correct at each mapping step. To evaluate the
effect of the intervention, the decrease in injury
incidence will be analysed in a cluster randomized
controlled trial.
The primary research questions addressed are:
‘‘What is the effect of the injury prevention programme
on lower extremity PA injury incidence
and severity?’’ and ‘‘What is the cost effectiveness
of this programme?’’
The secondary research question is: ‘‘What is
the effect of the injury prevention programme on
the improvement of knowledge, (determinants of)
injury-preventing behaviour and motor fitness?’’
6.1 Sample Size
A difference in the incidence of acute lower
extremity injuries of 7% between the intervention
and control group after 8 months is considered
clinically relevant. To detect a difference of 7% in
the incidence of lower extremity PA injures with a
power of 90% and an a of 5%, 500 children per
group (intervention/control) are needed in an
Table IV. Examples of the iPlay-programme of exercises used to prevent injuries
Strength Coordination Speed Flexibility
Forward jumps Passing the ball (one leg stance) Shuttle run Flexibility of hamstring
Squats to 80 of knee flexion Skate jumps Race course Flexibility of calf muscle
Hand wrestling in push-up
Pushing each other off balance (one leg
Spurts from different start
Flexibility of biceps
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ª 2009 Adis Data Information BV. All rights reserved. Sports Med 2009; 39 (11)
evaluation study. However, in order to perform
multi-level analyses taking into account a cluster
randomization design (schools as randomization
level) – with an intra-cluster correlation coefficient
of 10% and a dropout rate of 20% – a total
of 2280 children from 40 schools are required at
6.2 Recruitment
6.2.1 Recruitment of Primary Schools
The evaluation will be carried out in Dutch
primary schools. From the 7000 primary schools
throughout the Netherlands, 520 primary schools
are randomly selected from a database and invited
by means of an information flyer. Inclusion
criteria for the primary schools are: (i) being a
regular primary school; (ii) giving PE lessons
twice a week; and (iii) being willing to appoint a
contact person for the duration of the study.
A flowchart of the recruitment of primary
schools is given in figure 3.
6.2.2 Recruitment of Children and their Parents
The children and parents from the participating
schools receive an information letter about
the study design. All children are eligible for inclusion
in the study. The parents receive a passive
informed consent request: this consent procedure
assumes that the parents consent, unless the
researcher is contacted by means of a telephone
call or by sending an email.
6.3 Randomization
Schools serve as randomization units to avoid
spillover of the intervention within schools. A
stratified randomization is performed based on
geographic location (urban/suburban) and professional
status of the PE teacher (certified/
uncertified), resulting in four strata. From each
stratum, schools are randomly allocated to the
intervention or control group by a computerized
random number generator. Before the school
year starts, the primary schools are informed
about the group (intervention/control) they are
assigned to.
6.4 Primary Outcome Measures
6.4.1 Injury Definition and Registration
Throughout the school year, PA injuries
are recorded continuously by PE teachers. They
are instructed to question children explicitly every
week about whether they have been injured as
a result of PAs (including non-organized events)
in the past week. The injury definition, as described
by van Mechelen et al.,[9] is used where a
PA injury is any injury as a result of participation
in PE class, sport activities or leisure time PAs
520 primary schools
370 primary schools
did not respond at all
105 primary schools
not willing to participate
45 primary schools
willing to participate
Five primary schools were excluded:
– Only once-a-week PE class (n = 3)
– Change in teacher at the beginning of the school year (n = 1)
– Already participates in the study with another primary school (n = 1)
– No time (n = 58)
– Missing value (n = 15)
– Not relevant (n = 10)
– Already participating in other project (n = 8)
– No interest (n = 8)
– Change in teacher (n = 5)
Control group = 20 schools
(n = 1093)
Intervention group = 20 schools
(n = 1117)
40 primary schools
participate in the iPlay study
(n = 2210)
Fig. 3. Flowchart of recruitment in primary schools. PE = physical education.
Developing a Physical Activity Injury Prevention Programme 897
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with one or more of the following consequences:
the child (i) has to stop the physical activity and/
or (ii) cannot (fully) participate in the next
planned PA (applies also to planned leisure time
PAs) and/or (iii) cannot go to school the next day
and/or (iv) needs medical attention ranging from
onsite care (e.g. first-aid personnel) to personal care
(e.g. physiotherapist or sports physician).
In case of an injury, the child is asked to complete
an injury registration form. The injury registration
form collects information on injury type,
injury location, direct cause of the injury and activity
performed at the time of injury.
Injury incidence refers to the number of new
PA injuries during a particular period of time
(e.g. 1 year). One method to express incidence
rates is to calculate the incidence of PA injuries in
relation to exposure (in days, hours or sport
event). To determine time at risk for PA injuries,
all children complete a questionnaire in the
classroom twice a year. This questionnaire collects
information on exposure time (sports and
leisure-time PA participation).
6.4.2 Cost Effectiveness
In order to evaluate the cost effectiveness of
the preventive measure, all parents from children
who sustain a PA injury receive a cost diary. The
cost diary is a log in which parents register all
(para-) medical treatment (including use of medication),
absence from school and sport activities,
and other discomfort from the moment of injury
onwards, until full recovery. From these cost
diaries, direct and indirect costs resulting from
the sustained injury can be calculated for use in
the economic evaluation.
6.5 Secondary Outcome Measures
Knowledge, injury-preventing behaviour, behavioural
determinants and motor fitness are
measured at baseline (start of the school year)
and follow-up (end of the school year).
6.5.1 Questionnaires
Children are requested to complete a questionnaire
in the classroom. The children take
home the questionnaire to their parents, who are
asked to complete their questionnaire and return
it to the research team in a pre-stamped reply
Knowledge about injury prevention is measured
with one question on self-reported improvement
in knowledge of how to prevent PA
injuries, as well as a knowledge test including nine
multiple-choice questions about injury prevention
in general.
Behavioural determinants are assessed with
the following constructs: attitude, social influence,
self-efficacy and intention. The injurypreventing
behaviour is defined as wearing
appropriate protective equipment and footwear
during organized PAs, leisure time and PE class.
Attitude towards the injury-preventing behaviours
is assessed with three questions. Social influence
is assessed with questions regarding social
norm, modelling of friends, and modelling of
parents. Self-efficacy is assessed with two questions
relating to the child’s perception of their
ability to perform injury-preventing behaviour.
Intention and behaviour towards wearing protective
equipment and appropriate shoes during
organized PAs, leisure time and PE class are assessed
with one question. All answers on the
questions are given on a five-point Likert scale
varying from always (1) to never (5) or totally
agree (1) to totally do not agree (5). All questions
are positively formulated.
We pretested the questionnaires on comprehensibility,
(lack of) clarity and practical applicability
in 54 children and their parents. Based on
the results of the pretest, we changed some
questions to increase comprehensibility, deleted
excessive text messages and shortened the questionnaire
to decrease completion time.
6.5.2 MOPER Fitness Test
Motor fitness is assessed with the MOtor
PERformance (MOPER) fitness test. Supervised
by a research assistant, groups of three to four
children perform seven test items of the MOPER
fitness test (bent arm hang test, 10 · 5m run test,
plate tapping test, leg lift test, sit and reach test,
arm pull test and standing high jump test), and
they are asked to perform all test elements as
well as possible. For practical reasons, we decided
to exclude the 6-minute endurance run. For an
898 Collard et al.
ª 2009 Adis Data Information BV. All rights reserved. Sports Med 2009; 39 (11)
extensive description of the MOPER fitness test
items, see Leyten et al.[46] In addition, children
perform the flamingo balance test, which has
been described in the EUROFIT test.[47] To be
able to complete all tests during one PE class we
shortened the flamingo balance test to 30 seconds
instead of 1 minute as the original flamingo balance
test protocol indicates. All test items are
performed barefoot to rule out the effect of
footwear on the test results.
Body height and weight are also measured.
Body height is measured in metres to the nearest
centimetre with a portable stadiometer (Seca 214,
Leicester Height Measure; Seca GmbH & Co,
Hamburg, Germany). Asking the subject to stand
straight, with the heels together and looking
straight ahead, standardizes positioning of the
body. Body weight is measured to the nearest
0.1 kg with a digital scale (Seca 770; Seca GmbH
& Co, Hamburg, Germany). During the body
height and weight measurements, children wear
only underwear.
6.6 Statistical Analysis
The effects of the intervention will be assessed
using multilevel regression analysis. This statistical
technique takes into account the dependency
of observations of different children from the
same class and school. Analyses will be adjusted
for baseline values and, if necessary, for other
The economic evaluation will be assessed
using mean direct (i.e. medical costs), indirect (i.e.
costs for absence from school/work) and total
costs from the cost diaries. Because costs are
generally not normally distributed, 95% confidence
intervals for the differences in mean costs
will be obtained by bias-corrected and accelerated
bootstrapping. Differences in costs and
differences in injury incidence will be included in
a cost-effectiveness ratio, which estimates the
additional costs to prevent one PA injury.
6.7 Process Evaluation
A process evaluation is included to monitor
programme implementation, which will gain insight
into the relationship between specific programme
elements and programme outcomes.[48]
The injury prevention programme will be evaluated
with the use of the RE-AIM(reach, efficacy/
effectiveness, adoption, implementation and
maintenance) framework.[49] All PE teachers,
children and parents assigned to the intervention
group are asked to complete the process evaluation
7. Discussion and Conclusions
Regular PA has many health benefits, but also
increases the risk of PA injuries. This paper describes
how to develop and evaluate a preventive
measure using the IM protocol. To our knowledge,
this is the first time this has been done in
the injury prevention field. Although this strategy
has never been used before in this field, the underlying
systematic ‘evidence-based’ process and
the contribution of the field of practice make the
IM method likely superior to any othermethod for
developing an injury prevention programme.
The IM protocol provides a valuable checklist
for the development of an intervention programme.
However, it is a rather time-consuming
process. The research on determinants, definition
of suitable performance objectives, moving back
and forth between the IM steps, and the pretesting
of materials required much time. This makes
it sometimes difficult to apply the IM process
according to the full instructions.
The results of the evaluation study will be
published elsewhere. Preliminary analysis clearly
indicates that the iPlay study resulted in a significant
decrease in injury incidence in the intervention
group. Moreover, the results of the
evaluation study will help to gain more insight
into the effects of school-based injury prevention
The iPlay study is supported by a grant from the Netherlands
organization for health research and development
(ZONMW), grant number 62200033. The authors have no
conflicts of interest that are directly relevant to the content of
this review.
Developing a Physical Activity Injury Prevention Programme 899
ª 2009 Adis Data Information BV. All rights reserved. Sports Med 2009; 39 (11)
Authors’ contribution: EV was involved in developing the
concept and the design of the study. DC, MC and EV were
involved in further developing the idea and the protocol for
carrying out the study. DC was responsible for the data collection
and she drafted the manuscript. All authors contributed
to the final manuscript by reading and correcting
draft versions.
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Correspondence: Dr Mai J.M. Chinapaw, EMGO Institute
and Department of Public and Occupational Health, VU
University Medical Center, Van der Boechorststraat 7, 1081
BT Amsterdam, the Netherlands.
Developing a Physical Activity Injury Prevention Programme 901
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