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Qualitative research
Youth athletes at Swedish sports high schools with an athletics specialism emphasise environmental support for injury risk management: a focus group study
  1. Jenny Jacobsson1,2,3,
  2. Dejan Mirkovic3,
  3. Per-Olof Hansson2,4,
  4. Carolina Lundqvist2,5,
  5. Robert Henry Mann6,
  6. Ulrika Tranaeus7,8,9
  1. 1Department of Health, Medicine and Caring Sciences, Linköping University, Linkoping, Sweden
  2. 2Athletics Research Center, Linköping University, Linköping, Sweden
  3. 3Swedish Athletics Federation, Stockholm, Sweden
  4. 4Department of Management and Engineering, Linköping University, Linkoping, Sweden
  5. 5Department of Behavioral Sciences and Learning, Linkoping University, Linköping, Sweden
  6. 6Children's Health and Exercise Research Centre, University of Exeter, Exeter, UK
  7. 7The Swedish School of Sport and Health Sciences, Stockholm, Sweden
  8. 8Sport Performance and Exercise Research & Innovation Center - Stockholm, SPERIC-S, GIH, Stockholm, Sweden
  9. 9Unit of Intervention and Implementation for Worker Health, Institute of Environmental Medicine, Karolinska Institute, Stockholm, Sweden
  1. Correspondence to Dr Jenny Jacobsson; jenny.jacobsson{at}liu.se

Abstract

In this study, we examined knowledge and understanding of sport-related injuries among youth athletics (track and field) athletes and assessed their needs in managing any health problems. Qualitative data were collected via 12 focus groups with youth athletes (16–19 years) studying at Swedish sports high schools with an athletics specialism. All focus group discussions were audiorecorded and transcribed before being analysed using a thematic analysis approach. Four researchers independently reviewed the transcripts, generated codes and developed themes. Three overarching themes related to the athletes’ knowledge and understanding of sport-related injury were developed: (1) awareness of injuries, (2) perception of injuries, and (3) factors contributing to injuries. The youth athletes were typically uncertain about how to acknowledge a sport-related injury. They expressed that knowledge about injuries was obtained in part by reflecting on the lived experiences of their peers. It was also demonstrated that there appears to be a ‘culture of acceptance’ regarding injury occurrence. In contrast, causes of injuries were viewed as dependent on multiple factors (eg, lack of context-specific knowledge about training practices). Regarding athletes’ needs in managing injuries, an additional three themes were developed: (1) creating functioning elite sports environments, (2) application of knowledge and (3) fostering athletes. An apparent lack of structure and organisation related to the school environment was identified as an important issue to review to create opportunities for sustainable athletic development. The study identified areas that can be improved in Swedish sports high schools with an athletic specialism and could be applied in other youth sports contexts. The results of this study guide school stakeholders, alongside the sport governing bodies who have the mandate to influence activities in youth sports contexts, whereby special attention should be directed towards improving the social environment for youth athletes.

  • Qualitative
  • Performance
  • Adolescent
  • Sporting organisation
  • Sporting injuries

Data availability statement

No data are available.

https://creativecommons.org/licenses/by/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.

https://doi.org/10.1136/bmjsem-2022-001527

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    WHAT IS ALREADY KNOWN ON THIS TOPIC

    • Youth athletes studying at sports high schools are at high risk of sustaining injuries.

    WHAT THIS STUDY ADDS

    • Experiences of sport-related injury described by youth athletes highlighted uncertainty about how sport-related injury is acknowledged.

    • There appears to be a ‘culture of acceptance’ regarding injury occurrence.

    • Sport-related injuries were viewed as dependent on multiple factors (eg, lack of context-specific knowledge about training practices).

    • A clear structure in athletes’ social environment was important for fostering sustainable athletic development.

    HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

    • This study guides school stakeholders and sports’ governing bodies mandated to influence activities in these sports contexts.

    • The proposed influence of environmental-level and individual-level factors on injury incidence suggests that a multilevel model (eg, socialecological framework) is useful for conceptualising the issue.

    Introduction

    Studying at high school (ie, secondary education) represents a period when youth (adolescent) athletes are at a ‘development athletic level’ in most sports.1 This also represents a period in life when youth athletes are still under the responsibility and care of their parents/carers but when they also begin to make their own decisions about life and participation in sports.2–4 The opportunity to be a student at a sports high school (or sports academy) can facilitate the path towards a future career as an elite athlete.1 5 The overall aim of the sports high schools is to allow the students to have a ‘dual career’ by allowing them to combine secondary education and elite sports practice (eg, providing access to training facilities and time to practise their sport during typical school hours). Studying at this type of high school also means, in most cases, that youth athletes move away from home to a new environment. In Sweden, sport high schools are aimed at students aged between 16 and 19 who want to combine their secondary education with an elite sports education. These high schools—48 in total (representing 28 sports)—recruit nationally. That is, students from all over the country can apply. The education has a clear focus on elite sports. The Swedish school board approves the schools and is governed by the Swedish National Sports Confederation (https://www.rf.se). The affiliated national sports federation is the governing body for schools with a specific specialism.

    Research from several countries has shown that sports-oriented school environments are not all positive and can contribute to unwanted consequences, such as health problems (ie, injury and illness) and burn-out.6–9 For example, the burden of injuries in such school settings has been reported to be high; 4 out of 10 athletes are injured during training periods, and close to 8 out of 10 athletes sustain a new injury during a calendar year.6 8 In addition, it has been shown that an athlete who begins a season with an injury is more than twice as likely, compared with non-injured athletes, to sustain additional injuries during the season, which will greatly affect the athlete’s ability to participate.8

    Research in Swedish Athletics (SA) and at Swedish Sports High Schools, with an athletics (track and field) specialism (SSHS-A), has presented evidence that 16-year-old athletics athletes have almost the same prevalence and incidence of injury as older adult elite athletes over a full athletics season and that most injuries are related to overuse.6 10 Although these observations have been well documented, the literature is sparse on the underlying causes of the high injury rates in these sports-orientated school environments. This could be because most research has adopted prospective and longitudinal designs, almost exclusively focused on quantitative outcomes. Although useful, this approach will not provide a full and in-depth understanding of the context of existing problems.11 Also, research with youth athletes that has used mixed methods or qualitative approaches has shown that complex causal relationships (eg, between sleep and training volume) may exist.12

    As the governing body, SA is ultimately responsible for how the activities are conducted at the SSHS-A. To develop tailored interventions addressing ill health in these settings, SA needs to gain a deeper overall understanding of the reported problems from the stakeholders’ perspective of the reported problems.13 The need to supplement quantitative study designs with qualitative approaches has been emphasised.14 Moreover, this research project is also supported by previous research which emphasises the importance of involving end users (ie, youth athletes) early in the development and implementation of health programmes (eg, introducing measures to reduce injury risk) and that these programmes are contextualised to the specific age and social environment of the athletes.15 16 Because musculoskeletal injuries have previously been identified as a significant problem in this group of athletes,6 the initial objective of this study was to examine the knowledge and understanding of musculoskeletal injuries and their occurrence among students at SSHS-A. A second objective was to understand athletes’ needs in managing health problems in this setting.

    Methods

    Design

    This was a qualitative study using a descriptive exploratory approach. Semistructured focus groups were used for the data collection because we aimed to generate discussion among the athletes, thereby facilitating context-specific and in-depth insight. In this nationwide study, data were collected in six SSHS-A, including first- and third-year students (year 3 is the most students’ last year in high school). The analysis results are reported according to the Consolidated Criteria for Reporting Qualitative Research (online supplemental material).17

    Supplemental material

    Participants

    Schools were recruited by invitation from the Education Officer at SA. The director for the athletics programme at each SSHS-A (n=7) was first contacted by telephone. Then additional emails were sent to each high school approximately 4 weeks before each focus group. These emails described the purpose of the project and the procedures for the focus groups. One of the SSHS-A declined participation because the director in charge was ill. The director at each of the SSHS-A then informed the students about the purpose of the study, and they were subsequently invited to participate. We aimed to include all first-year and third-year student athletes studying at the SSHS-A, and, therefore, a purposive sampling method was used.18 Participation in a focus group was voluntary, and athletes could refrain from participating without providing a reason. No parental consent was required due to the age of the students. All participating students consented to participate in the study and for the focus groups to be audio recorded.

    Data collection

    Data were collected from 12 focus groups, including 6 in each cohort of students (ie, first-year and third-year students). Attendance ranged from 5 to 15 participants, and all focus groups took place between October and December 2018 in an auditorium at each SSHS-A. The mix of girls and boys was fairly even in each focus group, whereby the total number of participants per group mainly depends on whether the school is located in a larger or smaller town. Participant information is presented in table 1. Two representatives from the research group were present at all focus groups; one moderated the discussions (JJ; medical coordinator for SA, physical therapist), while the other recorded the focus groups and acted as a facilitator for the discussions (DM, head of dual careers at SA). The researchers’ collective knowledge and expertise were useful in building relationships and facilitating athletes who wanted to share their lived experiences. All focus groups followed the same standardised protocol based on a semistructured topic guide (see online supplemental material) and lasted for approximately 60 min. Each focus group began with a short introduction of all participants and was followed by a 5 min report of scientific findings from previous injury research conducted by SA and at SSHS-A.6 10 Each focus group was divided into two parts. First, the participants were asked to reflect on and discuss what could be the cause of the high incidence of injuries (ie, a health problem) at SSHS-A. In the second part, the athletes were asked to reflect on what needs to be done to reduce health problems and how a change can be achieved. Every focus group (including facilitator-participant interactions) was unique; different prompt questions were used to encourage in-depth responses. All focus groups were audiorecorded and transcribed verbatim after the final focus group. Focus group transcripts were then circulated to four researchers in the team (JJ, DM, P-OH and UT), the latter two with experience in psychology, pedagogy and qualitative research. All audio files were permanently deleted after transcription.

    View this table:
    Table 1

    Description of the participants

    Data analysis

    Data collected from the 12 semistructured focus groups were used in the analysis. The analysis started after the last focus group, and investigator triangulation was used to support the conclusions.19 The data from the focus groups were analysed inductively (ie, directed by the content of the data) using a thematic analysis approach.20 This six-stage process enables data to be developed into codes and themes. In the first stage, the transcripts from all focus groups were reviewed independently by four researchers (JJ, DM, P-OH and UT) who familiarised themselves with the data. Two of the authors (JJ and DM) at the focus groups used a latent approach (ie, identifying underlying ideas/assumptions) when analysing the transcripts. The second and third stages included individual attempts to code and develop these codes into themes. In the fourth stage, all four researchers compared and discussed the codes and themes at a face-to-face meeting. Any discrepancies between the independent coding and themes were discussed in the fifth stage until a group consensus was reached. The sixth and final stage involved writing up the data. The agreed codes and themes were then reviewed independently by two researchers (CL and RHM) who had not taken part in the study design or initial data analysis. This process was used to ensure that the codes and themes were appropriately challenged and understood according to this study’s objective(s).

    Results and discussion

    Regarding the first objective of the study, to examine youth athlete’s knowledge and understanding of musculoskeletal injuries in the sport, the following three themes were generated from the focus group discussions: (1) awareness of injuries, (2) perception of injuries and (3) factors contributing to injuries (table 2). Further, three themes were generated regarding the second objective of the study, which describes athletes’ needs in managing injuries (table 3), as follows: (1) create functioning elite sports environments, (2) application of knowledge and (3) foster athletes. Overall, these themes show that transitioning from being a talented youth athlete to having a career as an elite adult athlete is a complex path with several possible obstacles, as supported by previous literature.21 22

    View this table:
    Table 2

    Athletes’ perceived knowledge of injuries

    View this table:
    Table 3

    Athletes’ description of their needs for injury management

    Athletes’ perceived knowledge of sport-related injuries

    Awareness of injuries

    The definition of an injury can be viewed from various perspectives; for example, sports impairments rely on accurate athlete self-reporting of health problems.23 The youth athletes at SSHS-A displayed uncertainty about how to acknowledge an injury in the sport and when they should consider that they are injured. As one athlete expressed, ‘I’ve had niggles, it’s not that, but I’ve never gotten so far that I’ve really thought there were injuries.’ Similar findings have been observed in other sports environments among athletes of the same age.6 24 In addition, these youth athletes expressed that, in part, knowledge about injuries was obtained by reflecting on injuries that their peers experienced; ‘There are many who have been injured, so you have an idea.’ This uncertainty shows that the athletes may lack certain important information to be able to perform their sport (eg, on how to interpret body signals). A preventative behaviour has been described as developing over time, related to own injury experience.25 However, from the view of the sport and key stakeholders, it should be considered unacceptable that young talented athletes must experience periods with injuries to provide them with the tools necessary to deal with any future injury problems.

    Perception of injuries

    Doubts were expressed about applying to SSHS-A if one did not feel physically prepared. As one athlete put it: ‘The body was not 100 percent.’ This signals that when athletes begin their studies, they may believe that the focus of SSHS-A is primarily on physical performance and that they do not fully comprehend the purpose of dual career education. Such reasoning is problematic, and sports federations and schools need to identify and understand these athletes to provide the necessary support to avoid the risk of talented athletes dropping out.26 Furthermore, expressions from the focus groups indicate that there appears to be a well-embedded culture of acceptance that injuries will occur within the sport. If such a culture exists, one consequence is that experiential pain is ‘normalised,’ that is, the young athlete may not understand or even dare to express that they have a problem.27 As a result, youth athletes may be training and competing while experiencing a health problem.28 The problems that can arise due to a hidden cultural adaptation (ie, ‘silent issue’) have been highlighted as important to identify so the situation can be remedied.29 In addition, athletes at some SSHS-A experienced difficulties in receiving proper support for perceived health problems, exemplified by the following quote: ‘It’s very much an ‘assembly line,’ in with the next one, out with that one, and so on’. If they received support, this was described as being strongly dependent on, for example, the coaches’ personal experiences rather than an overall structure in the school environment as put by one athlete: ‘He has like all the time asked how my injury is going’.

    Factors contributing to injuries

    Training structure and its possible relationship with injuries was widely discussed in all focus groups. The athletes expressed a lack of context-specific knowledge and experience of a one-sided structure, for example, about meal planning and how training is conducted: ‘It is important to know from the beginning that you are doing them (exercises) correctly […].’ The reflections of the athletes show a need to acquire in-depth knowledge early in their sporting and academic careers about the specific loads and possible risks in their sport.

    The biopsychosocial model describes that an individual’s health or ill health can depend on biological, psychological and social aspects that interact to varying degrees.27 One athlete’s statement, ‘If I think I need to do my rehab, then there shouldn’t be anyone who sort of argues against it […]’, reflects that athletes may experience stress or frustration in having to explain the situation and experience inadequate communication with/between coaches, instead of being supported by them. The latter highlights the importance of a closer dialogue with (and support from) coaches to enable the athlete to navigate health risks better. Overall, in line with what has been observed previously, this research suggests that the causes of sports injuries are dependent on multiple factors.12 27

    Athletes’ description of their needs for injury management

    Create functioning elite sport environment

    The environment in which the athletes find themselves and how it can affect performance, well-being and longevity in the sport has been emphasised in several studies.5 30–32 In our study, the athletes’ perceived lack of structure and organisation related to the school environments was discussed in the focus groups. It emerged as possibly the most important issue to review to create opportunities for sustainable sports development. For example, the athlete’s description of a lack of opportunity to receive support for academic studies during scheduled school time—‘we never have time to go to those sessions because, because we have often training during them’—reveals that some schools may not fully grasp the extent of the athlete’s studies and training routines. This points to an important area that should be straightforward for schools to address, for example, when planning students’ schedules. The purpose of SSHS-A environments is to support the athlete’s personal development and provide opportunities for a dual career. The SSHS-A’ holistic approach was emphasised by the athletes as important for their study time at the school. In addition, perceived shortcomings in the school networks were also discussed, such as difficulties in accessing various resources (eg, physiotherapists, dietitians and sports psychologists) when needed. Thus, there is a need for SSHS-A to review the various collaborations so that school-related resources that are to be provided are available in a similar way regardless of which school one attends, regarding, for example, accessibility.

    Application of context-specific knowledge

    There is an assumption that a certain level of knowledge (eg, risk literacy) should exist for an understanding of a problem to exist.15 The athletes often described how individualised programmes and advice provided increased understanding that helped them manage their training and injuries: ‘As a runner, I check the number of miles a week, for example, to make sure I don’t run too much.’ The importance of factual and conceptual knowledge to understand complex relationships and take personal responsibility for preventing health problems in athletes has been highlighted.22 33 34 This highlights that the sports subjects on the schedule may need to be revised so that, in addition to the basic generic information, they also contain sport-specific knowledge that the athletes can relate to.35

    In addition, the athletes’ lack of understanding of why, for example, special exercises (resulting from screening) are introduced as prevention shows that existing models for knowledge transfer do not seem to work. Knowledge translation refers to how complex information is translated and made understandable and useful to intended consumers. Actions that support both knowledge translation and delivery have been identified.36

    Fostering athletes/education

    The concept of learning is a process that can be problematised in a broader sense and includes the need for informal learning alongside purely theoretical formal learning.37 Contextual, informal or formal learning can transform knowledge into a structure of understanding to support athletes’ self-management.13 37 To avoid and manage the consequences of health problems, the results of this study indicate that SSHS-A should have a clear structure for individually adapted study and training plans that are regularly monitored and evaluated for each athlete. Such an understanding (ie, taking an individualistic approach) supports the development of life skills and should enable youth athletes to balance their dual career opportunities.26 38

    In summary, several needs have been identified that need to be met to give students at sports high schools better conditions to deal with possible injuries. Future measures should be aimed at multiple levels, ranging from how the Sports High School is organised with, for example, supporting network (organisational level) to provide the individual athlete with factual knowledge that increases his understanding of the complex relationships around injury management (intrapersonal level). This emphasises that a socioecological framework is useful for planning future interventions.39

    Methodological considerations

    While a qualitative study design is a useful approach for exploring how the problem of injury is experienced and defined by youth athletes, various methodological considerations need to be discussed. For example, when framing generalisability from a ‘statistical-probabilistic’ perspective, the results of this study should be viewed as being context-specific, and caution should therefore be applied if looking to generalise the findings to other age groups and/or contexts outside of the Swedish and/or Scandinavian high school model. The investigator triangulation method used in this study supports the trustworthiness of the findings. This claim of trustworthiness, in this case transferability, is also supported by the fact that a degree of similarity was demonstrated between the findings presented in this study and previous literature. We believe that the researchers’ expertise combined with their different backgrounds enabled a rigorous analysis process, and resulted in findings that comprehensively describe the data collected. Transferability was met by including quotes in tables 2 and 3. However, as with all qualitative research, the researcher’s own experiences and views influence the interpretation of the data—upheld here as a positive element of the study.

    Conclusion

    The process of compiling the youth athletes’ experiential knowledge showed that the journey from talent to the elite is influenced by several factors, some of which are seemingly particularly important to consider to achieve good health during academic studies at SSHS-A. The proposed influence of environmental-level and individual-level factors on injury incidence reported in this study suggests that a multilevel model, for example, a socialecological framework, is useful for addressing the question at issue, protecting the athlete’s health.21 40 41 Several proposed areas that could be implemented in the SSHS setting emerged during the focus groups. The results of this study thus guide school stakeholders and sports governing bodies who have the mandate to influence the activities in these sports contexts, whereby special attention should be directed towards actions in the athlete’s school social environment. The needs described are based on the athlete students’ experiences. Therefore, future action programmes and strategies implemented within SSHS-A will likely have the support and be taken up more effectively by intended users.

    Data availability statement

    No data are available.

    Ethics statements

    Patient consent for publication

    Ethics approval

    This study involves human participants and the study followed the World Medical Association Declaration of Helsinki Ethical Principles for Medical Research Involving Human Subjects. No personal health data were collected from the participants in the focus groups. All data were collected and presented at group level. The transcripts from the focus groups were anonymised. The study protocol was reviewed and approved by the Medical Committee of SA in June 2018. Participants gave informed consent to participate in the study before taking part.

    Acknowledgments

    We would like to acknowledge all youth athletes who participated in this study for their time and enthusiasm.

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    Supplementary materials

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    Footnotes

    • Twitter @Jenny_Jacobsson, @CarolinaLundqv1, @Robert_Mann_

    • Contributors JJ conceived and designed the research project and coordinated the development of the study. JJ and DM were involved in data collection. JJ, DM, P-OH and UT were involved in the analysis of the data. CL and RHM reviewed the resulting analysis. All authors made substantial contributions to data interpretation. JJ made a substantial contribution to drafting and writing the article. All authors were involved in revising the manuscript and final approval of the version to be published. JJ is the guarantor of the study.

    • Funding The study received research support from the Swedish Sports Confederation and the Swedish Athletics Federation.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.