Department of Public and Occupational Health

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
ª 2009 Adis Data Information BV. All rights reserved. Sports Med 2009; 39 (11)
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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