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This study adheres to the Standards for Reporting Qualitative Research (SRQR) (https://www.equator-network.org/reporting-guidelines/srqr/). Preliminary data were presented as abstracts at scientific conferences 2023 [20, 21].
Guiding theories
Identified barriers and facilitators from our previous studies within I-PROTECT [10, 17, 18] informed the development of the content (information, physical and sport psychology exercises) and delivery of the intervention, categorized according to relevant topics in the Innovation domain of the updated Consolidated Framework for Implementation Research (CFIR) [22]. Barriers were mainly related to lack of knowledge and time, while facilitators were principally about to be well informed, have end-user-targeted information and training, and have programs with selected exercises along with the option to choose exercise/level of progression (Appendix A).
The behavioral theory Health Action Process Approach (HAPA) [23], and the motivational theory Self-Determination Theory (SDT) [24], guided the development of information and exercises to facilitate behavior change and motivation. The HAPA theory [23] was used to ensure motivational and volitional (action) strategies. SDT was used to promote high quality motivation by considering the three basic needs autonomy, perceived competence, and relatedness [24]. In addition, goal setting principles [25] were applied to develop information about implementation for club administrators.
Information
The research team developed information regarding importance, benefits, and principles of injury prevention training, load management, and communication and feedback targeting the different end-users. Also, information about implementation was developed for club administrators. The research team (authors of this paper) represented different expert fields (both theory and practice) as follows: EA was a senior researcher with a PhD in medical sciences and expertise in physical therapy and sports medicine, and 12 years of clinical experience in sports injury rehabilitation. KM was a junior researcher with a PhD in sport sciences and a PhD in sport psychology, and 19 years of clinical experience as a sport psychology consultant. SB was a junior researcher with a PhD in sport psychology and 12 years of experience working with youth as a teacher in a sports high school. JL had an MSc in sport psychology, experience as an elite handball player (13 years), coach (8 years), coach educator (8 years) and sport psychology consultant (2 years).
Training
Handball-specific exercises including injury prevention principles, injury prevention strength exercises (body weight for young players, weight training for older players), and sport psychology exercises were developed, based on the needs identified in previous studies [10, 18]. Figure 1 provides an overview of the development of the intervention (information and training).
Handball-specific exercises
Building on previous results [10, 18], research team members (JL, EA) continued to develop handball-specific exercises including physical principles of injury prevention (movement technique upper and lower extremities, respectively, and muscle strength) combined with psychological aspects (increase end-user motivation, task focus and body awareness) to integrate in handball practice warm-up and skills training for coaches to do with their team(s).
Strength exercises
Three workshops were held to develop handball-specific strength exercises. Three authors (EA, JL, SB) prepared the workshops and invited players, handball coaches, strength and conditioning coaches, and physical therapists to participate. Given our previous experience with conducting workshops [10], and that players and coaches are generally well familiar with strength training, the research team decided to have a first workshop with experts and end-users together. The subsequent workshop built on the previous one.
In the first workshop (face-to-face, February 2020), participants developed and tested injury prevention principles and exercises that youth handball players (15–17 years) could integrate within their strength training. All participants had experience in handball. Participants who volunteered to participate were: Six youth players (3 male and 3 female, all aged 16–17 years) and two coaches (1 man and 1 woman; one was a clinically active physical therapist and a strength and conditioning coach in a handball club, and the other was a physical therapy student) recruited from teams with players 15–17 years of the two clubs participating in the I-PROTECT study [16]; one clinically active physical therapist and former elite handball player (female); and two strength and conditioning coaches (2 men, both worked at a gym and had extensive experience in strength and conditioning training for youth and elite handball players). Three authors (EA, JL, SB) led and facilitated the 2.5-hour structured workshop.
The workshop started with an introductory didactic session to provide participants with information about the I-PROTECT project, and results from previous studies within the project, including the mobile application I-PROTECT GO [10, 17, 18]. Participants were then divided into four groups: (1) Female players (n = 3), (2) Male players (n = 3), (3) Handball coach, strength and conditioning coach, and physical therapist (n = 3), and (4) Handball and strength and conditioning coaches, and one author who was also a handball coach and former elite player (n = 3). The other two authors circulated between groups 1, 2 and 3, to answer questions and/or reinforce the task(s) and goal of the workshop. The players (groups 1 and 2) were asked to discuss what type of strength exercise content players want/need, how they wanted this material to be presented, how they believed that strength training could be presented/delivered to enhance motivation for uptake, and to provide examples of exercises. Group 3 was asked to focus on the lower extremities and group 4 on the upper extremities and core. Groups 3 and 4 were asked to provide examples of exercises to improve strength and reduce the risk of injury, emphasize important injury prevention principles, and describe important general exercises. Workshop participants documented their results, presented results in the whole group, and gave each other input. Research team members documented results from the discussions in small groups and the whole group. Based on the results from this workshop, research team members (JL, EA) continued to develop strength exercises and planned the following workshop.
In the second workshop (held over Zoom, February 2021), strength programs were developed. A 3-hour workshop was led by two authors (JL, EA). Two strength and conditioning coaches (men) and two clinically active physical therapists specializing in sports medicine (1 woman, 1 man) participated. All four had handball knowledge. Participants were provided with a summary of results from previous I-PROTECT studies, results from the first workshop, and questions to discuss, before the workshop. The two strength and conditioning coaches participated the first 1.5 h to discuss setup and structure of programs, exercises, instructions, programming (sets, repetitions, time, load), and periodization. The two physical therapists joined the last 1.5 h of the workshop, in which participants were divided into two groups to discuss the bank of exercises with focus on the content (strength and conditioning coaches) and principles of injury prevention (physical therapists), respectively. Each group then summarized their discussions in the whole group.
More time was required to discuss all exercises from principles of injury prevention. Therefore, a third 1-hour workshop (face-to-face, April 2021) was held with the two physical therapists by one author (JL) in which the remaining exercises were discussed. Also, strength exercises (body weight or low weights/resistance) for players 13–14 years were discussed.
The authors documented and synthesized the results. The experts were asked to provide any feedback on the synthesis. A film production company was appointed to produce videos of exercises, and elite/professional and youth players were recruited to demonstrate the exercises.
Sport psychology exercises
Given that players and coaches were generally unfamiliar with sport psychology exercises, experts initiated the development of these exercises and end-users then tested and evaluated them. The three first steps of the generalizable six-step intervention development process [26] were followed: (1) identify and synthesize research evidence and clinical experience; (2) consult relevant experts and (3) engage end-users to ensure their needs, capacity and values were considered.
First, peer-reviewed literature was searched to identify potential sport psychology exercises. In this literature search, central publications on the topic in focus (i.e., injury prevention and psychological interventions for injury prevention) were identified. Also, potential interventions within the topic stress reduction and within the focus areas self-reflection and self-awareness, interpersonal knowledge, arousal regulation, mindfulness training, psychoeducation (e.g., the importance of recovery), motivation and goalsetting, all of them emerging from the results of the sport psychology expert workshop 2018 [10], were identified. The synthesis of the results was guided by one author’s (KM) clinical experience and consisted of a first version of principles and exercises for injury prevention from a psychological perspective. Regular meetings were held, in which two authors (SB, JL) provided feedback on the process, and decisions were discussed.
Second, experts in sport psychology were consulted to evaluate the exercises that were developed in step 1 to ensure quality of the content. Players’ exercises and exercises for coaches to do with their team(s) were presented and discussed in two separate workshops (a 2-hour online workshop about players’ exercises, December 2020; a 1.5-hour online workshop about coaches’ exercises, January 2021) with one of the experts who participated in a previous I-PROTECT study [10]. Discussions centered around the meaningfulness and feasibility of the exercises, as well as the age appropriateness of the exercises. This expert was chosen as he had expertise in both sport psychology (PhD, and sport psychology consultant) and handball (youth coach). Both workshops were led by two authors (KM, SB). The sport psychology experts (n = 4) who participated in the previous I-PROTECT study [10], and were not part of the research team, were asked to provide feedback on the sport psychology principles and exercises for injury prevention.
Third, a workshop with handball players from an elite sport high school was conducted to receive feedback about the sport psychology exercises for players. All students in the second and third years (n = 18) were invited and seven female players, all aged 18 years, agreed to participate. A 2-hour workshop was conducted online (December 2020), led by two authors (KM, JL). After a short introduction with information about the I-PROTECT project, four exercises were presented to the participants. The participants were then asked to discuss these exercises and provide feedback about (i) content; (ii) instructions; (iii) potential improvements, and (iv) appropriate age span for each exercise.
Mobile application
As requested by end-users [10, 18], we continued to develop the mobile application (I-PROTECT GO), building on the first prototype [10]. While the first prototype targeted coaches only [10], modules for players, coaches, club administrators, and caregivers was developed in the present study. Information Technology consultants were appointed to produce the mobile application.
Feedback from early end-users
Six coaches, three players and one club administrator, previously not involved in the I-PROTECT project, tested the intervention for 6 weeks. They were interviewed (data from pilot study, ClinicalTrials.gov Identifier: NCT05304507) about their experiences about the content, delivery, and implementation of the intervention. Participants were also asked to provide any ideas for future improvement to help implementation of the intervention.
The six coaches (two female and four male coaches representing four different teams) participated in one of two focus group interviews shortly after the intervention was completed (May 2022). The interviews were led by two authors (JL on site and KM online). The three players (males aged 14 years from the same one team) participated in individual interviews held online (KM) after their team had tested I-PROTECT GO (March 2023). The club administrator was interviewed (May 2022) online (EA, JL).
The procedure and analysis were similar for the focus group and the individual interviews. Participants were first informed about the topic and the process of interviews. Based on an interview guide, the participants were then asked to share their experiences of the content of the intervention, and their general opinion of the mobile application. Follow-up questions were used to encourage participants to expand on responses and to further gather participants’ experiences of facilitators and barriers for sustained use. The focus group interviews with coaches lasted 55 and 57 min, respectively, the three individual interviews with players lasted between 30 and 35 min, and the interview with the club administrator lasted 51 min. All interviews were video and audio recorded. The interviews with coaches and players were transcribed verbatim, and participants were deidentified in the interview transcripts. Data analysis was guided by the principles of the general inductive approach [27] by one author (KM) using QSR International’s NVivo 12 qualitative data analysis software (released March 2020), and another author (SB) acted as critical friend for the analysis. The interview with the club administrator was summarized descriptively (EA, JL) regarding barriers and facilitators for content, delivery, and implementation of the intervention, respectively.
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