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Getting sports injury prevention on to public health agendas – addressing the shortfalls in current information sources
  1. Caroline F Finch
  1. Correspondence to Caroline F Finch, Australian Centre for Research into Sports Injury and its Prevention (ACRISP), Monash Injury Research Institute (MIRI), Monash University, Clayton Campus, Melbourne, Victoria 3800, Australia; caroline.finch{at}monash.edu.

Abstract

Public health policy is a successful population-level strategy for injury prevention but it is yet to be widely applied to the sports sector. Such policy is generally coordinated by government health departments concerned with the allocation of limited resources to health service delivery and preventive programs for addressing large community health issues. Prioritisation of sports injury prevention (SIP) requires high-quality evidence about the size of the problem and its public health burden; identification of at-risk vulnerable groups; confirmed effective prevention solutions; evidence of intervention cost-effectiveness; and quantification of both financial and policy implications of inaction. This paper argues that the major reason for a lack of sports injury policy by government departments for health or sport to date is a lack of relevant information available for policy makers to make their decisions. Key information gaps evident in Australia are used to highlight this problem. SIP policy does not yet rank highly because, relative to other health/injury issues, there is very little hard evidence to support: claims for its priority ranking, the existence of solutions that can be implemented and which will work, and potential cost-savings to government agencies. Moreover, policy action needs to be integrated across government portfolios, including sport, health and others. Until sports medicine research generates high-quality population-level information of direct relevance and importance to policy makers, especially intervention costing and implementation cost-benefit estimates, and fully engage in policy-informing partnerships, SIP will continue to be left off the public health agenda.

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Introduction

Public health policy is a well-used and successful population-level strategy for injury prevention.1,,4 It is somewhat surprising, therefore that it has not also been widely applied to the sports safety sector.5 In 2008, Timpka and colleagues6 called for “establishment of the sports injury problem as a critical component of general global health policy agendas”. Public health policy is the desired outcome of public health efforts concerned with sports injury prevention (SIP) at the population level.

There is certainly a science behind policy setting7 8 and epidemiology, as one of the very rigorous methodological approaches, it provides key information that is used to justify government investments in prevention, funding, data systems and research. The SIP field has been conducting epidemiological studies since the early 1990s, yet many have been purely descriptive in nature9 10 and very few can show direct impacts on public health policy. The accumulating epidemiological evidence over the past 15+ years has led to an increased national and international sports body focus on the problems of and commitment to finding and implementing solutions to address it.11 However, it is not at all clear whether the research has also led to new public health policy initiatives. With increasing efforts to engage more of the population in physically active lifestyles,12 and recognition of the range of adverse outcomes that can accompany any injuries sustained during such activity,13 it is timely to revisit why SIP is not on the public health agenda in many countries.

This paper argues that the major reason for a lack of sports injury public health policy by government health and sport departments, as well as other agencies, is a lack of the right sort of information that policy makers need to draw on on order to make their decisions. As a point of example, Australia, like most other countries, has no national (or state-based) SIP policy or lead agency. The key information gaps that are evident in Australia are used to highlight the nature of the problem.

Questions underpinning policy development and prioritisation

From a sports body and sports medicine perspective, the key sports injury/injury prevention questions that need answering include:

  • Which of our athletes are more at risk of injury?

  • How do these injuries affect the game and/or athlete performance and/or team success?

  • What medical services are needed to manage these injuries?

  • What are the risk factors for these injuries and how could athletes be better prepared against them?

  • What changes to the game, preparation regimes, equipment, facilities, rules, and so on can be implemented to prevent injury?

  • How can the adverse impact of injury and injury risk be minimised in athletes?

Responses to these questions have been driven, quite appropriately, by clinical and individual-focused approaches but it is not clear that these same individually-targeted prevention approaches in response to them can directly translate well to broad communities/groups/settings that are relevant to a population-health focus.

In the broadest sense, public health is typically a government responsibility, coordinated by government health departments and related sectors that are concerned with the allocation of limited resources to health service delivery and preventive programs aims at addressing large community health issues. Table 1 lists key questions that are of most of relevance to government departments for an issue to be put on their agenda.

Table 1

Public health questions that government health agencies need answers to before prioritising and setting sports injury prevention policy

Is sports injury a large enough population problem?

Government agencies will only act if there is strong evidence of a big (population-level) problem that needs to be addressed. Prevention of injuries, including via policy action, cannot occur without good quality, accurate, reliable and timely data about the size of the problem.14 15 In general, government health departments look to routine population-wide mortality or morbidity (generally from hospitals) data collections, to answer these questions.15 Unfortunately, the different data sources they use rank the importance of sports injuries differently. Data regarding deaths do not feature sport prominently and hospital admissions data rank sports injuries very much lower than other injury causes. On the other hand, sports injuries are a major source of emergency department presentations, and are the leading cause of child injury emergency department visits.16 Because sport does not rank highly as a cause of injury mortality/major morbidity this limits its ranking as a priority by government health departments, as well as international bodies such as the WHO and the Global Burden of Disease and Injury estimates.17

Routine health sector injury surveillance data are usually coded to the International Classification of Diseases (ICD-9 or 10) and injury cases are identified through a principal diagnosis of injury and/or an external cause code. The ICD-10-AM (Australian modification), used in several jurisdictions, includes >200 activity codes for identifying the specific types of sport/leisure activity of the injured person at the time the injury event occurred,18 as well as place codes to broadly identify the place of occurrence of event at the time the person was injured (including sports/athletics area).19 Of course, these codes are only useful if they are applied with high quality and completeness. There is evidence that there are a relatively large number of instances in which activity codes are not provided for injury hospitalisations and so it has been estimated that ICD-10-AM-activity coded data may still underestimate the true incidence of cases by 6.0–22.9%.18

Notwithstanding this sub-optimal case ascertainment, such data can still be used to estimate trends in population rates of hospitalised sports injury, especially if an assumption is made of non-differential case-ascertainment over the period of interest. In New South Wales (NSW), Australia, an analysis of routinely-collected hospital admissions data for the period 1 July 2003–30 June 2008 estimated the overall sports injury hospitalisation rate to be 195.5/100 000 residents and for there to a non-significant annual decline over the 5-year period.20 Unfortunately, however, injury hospitalisations are only the tip of the iceberg because the vast majority of sports injuries do not require attention by medical professionals, let alone in a hospital setting.21 This was assessed directly in NSW in the midpoint of the interval used for the above trend analysis of hospitalisations. People who reported sustaining a sports injury were asked to indicate where they received treatment for this injury, and specifically targeted questions were analysed in the annual NSW Population Health Survey.22 Only 2.8% of the sports-injured respondents were admitted to hospital for that injury. Added to this, 6.1% stated they were treated in a hospital emergency department, totalling only 8.9% of population-level sports injuries treated in hospital settings.

These findings have significant implications for the ability to answer the first major question in table 1. For most sports injury cases that are not treated at a hospital, even when they are recorded in routine databases, case ascertainment is incomplete. This is a significant problem because government health departments generally only rely on routinely-collected data from hospitals. Another implication is that despite several years of sports agency attention in NSW, there has been no significant decline in sports injury hospitalisation rates.20 The reasons for this are unclear but are likely to be related to the implementation and dissemination of injury prevention measures, or the lack thereof. Perhaps there has been wide scale non-adoption/non-translation of evidence-based approaches. Perhaps the current interventions (most of which have been derived from more clinically-orientated approaches) are not suited for wide-scale delivery and adoption; implementation approaches could be too diffuse or diluted; or the right population groups not targeted. Without concurrent evidence about barriers against, and facilitators for, intervention delivery and uptake it is not possible to identify whether or not these factors have made a difference.23 There may also have been changes in participation rates over the same period of time, but without good population level data on this that cannot be determined either.

Which parts of the community are most vulnerable?

Most government health departments recognise population-health differentials and that there can be significant social/cultural/economic determinants of ill health and increased injury rates that are exacerbated by factors such as where and how people live. Not much is known about this in relation to sports injury but one Australian study showed that sports injury rates were highest in the second and third highest quintiles of social disadvantage and lowest in those with greatest social disadvantage, perhaps reflecting a reduced rate of participation in sport in that group. In contrast, age-standardised hospitalisation rates were significantly higher in remote and very remote communities, though the full reasons for this are unknown.

Epidemiological studies consistently show that the population groups with high injury frequency and rates are males (of all ages) and children/younger people aged 10–40 years, with a peak injury hospitalisation incidence around 15–25 years.20 24 In Australia, population-level sport injury hospitalisations are most commonly associated with the football codes, other team ball sports (eg, netball and basketball), forms of active transportation for sport/recreation (eg, cycling, skating/blading), equestrian sports and ice/snow sports.24 25 These figures are consistent with what is known about population-wide sport participation levels.

There are several implications of these findings including the fact that sports injury is a young–middle-aged person's issue, a population group with relatively low overall use of hospital service delivery. Team ball sports and transport-orientated activities predominate as settings for the injury events. However, government health departments have no jurisdiction over these activities, as they play no role in the delivery of sport.

Although there are likely to be population disparities in sports injury rates, at least when measured by hospitalisations and by location of residence, the reasons for this are unknown. For example, is the solution to do with sport/leisure infrastructure provision, participation in sport/leisure pursuits, availability and provision of medical and allied health services or even opportunities for formal sport versus leisure? In any case, government health departments do not traditionally play a major role in implementing/supporting most of these solutions and this means that it is very hard for them to identify a role for themselves alone.

Why should the government address the issue?

Even when there are data to illustrate that sports injury is a significant public health issue, and is associated with socio-economic disparity, there is still a need to demonstrate why government health departments specifically need to address it. Why should it be their responsibility rather than that of individuals, communities, industry or even other government sectors? In the main, this come from demonstrating that there would be significant costs to government health departments for not acting and significant benefits if they did.

Table 2 shows previous ratings of the broad level of evidence for SIP, as presented in Australian Commonwealth Health Department reports.26 27 While developed in the Australian context, these ratings draw on the best international evidence and well represent the international status. The last column in the table gives an up-to-date assessment of the knowledge base and highlights continuing significant knowledge gaps. Most notably, these relate to incomplete knowledge about the size of the public health sports injury burden, very little evidence about the existence of effective prevention solutions, a total lack of implementation activities across the population and no information at all about cost-effectiveness or cost–benefit scenarios associated with investments in the interventions at the population-level. The clear conclusions from these knowledge gaps is that there is no information available to government health departments to justify why they should invest in public health approaches to SIP.

Table 2

Summary of the status of the population-level evidence and knowledge base for sports injury prevention*

Summary of the current status

In Australia, as elsewhere, while the past decade has seen a large increase in knowledge about injury risk factors and potential solutions to reducing these risks, most interventions remain largely untrialled; the effectiveness of implemented solutions is not known and there is no information about the cost-effectiveness of potential interventions or the likely benefits of their introduction. Table 3 summarises the status of answers to the policy questions posed in table 1. As can be seen, there are very clear gaps in the knowledge base and so it is not surprising that that there is currently no co-ordinated governmental response to the sports injury problem in Australia. This paper has illustrated the key arguments with data from Australia but the implications and conclusions have broad applicability globally.

Table 3

Information gaps in relation to the policy questions in Australia

Challenges for better information provision to the public health sector

Public health policy and practice need to be informed by good population epidemiological data. Information from a more clinical or local perspective is valuable, but in practice it will have very little bearing on government departments' policy makers if it is considered too specifically for a small sector of the population.

The needs of government health departments are very different to those of government sports departments, sports bodies and sports medicine practice/service delivery, sporting teams and athletes. The former care about the physical, mental and social health of populations and are keen to both improve, and reduce the cost of, health service delivery. This includes injury treatment/prevention services; however, this is often not forefront in their minds when there is much better evidence for higher priorities and benefits presented to them for other health concerns. A related issue is that injury severity definitions favoured by government health departments are different to those which are strongly promoted in consensus statements for sports injury surveillance.28 29 Government health departments have little interest in injuries that do not have a significant impost on the health system, even if they are frequent. This means that reporting of injuries that require little medical treatment but yet lead to considerable time away from sport are not relevant, irrespective of how important they are for sports delivery, sports bodies and the individual athletes involved.

As with other forms of implementation for sports safety, the culture within which government health departments operate significantly influences the extent to which they engage with a particular health issue.8 Importantly, unless government health departments (who bear the cost) are convinced that they have a key role in SIP and that there will be significant (cost) implications to them if they do not invest in this, then SIP will never make it to the public health agenda. Unfortunately, the status of most population-level data and other information are not sufficient to even start to convince them.

The sports medicine community needs to rise to the changes of providing government health departments with the necessary information to convince them otherwise; it is not realistic to expect them to find this themselves. In fact, sports medicine needs to embrace this as one of the key challenges it faces both in terms of recognition and support for its clinical services and their contribution to health service delivery, but also for how SIP evidence can contribute to broader preventive health strategies. In the injury prevention field there are some very strong models of success in relation to exercise prescription for falls prevention and road safety (eg, bicyclist safety).30

Sports medicine needs to generate and disseminate new high quality injury data at the population level to define properly the magnitude of the sports injury burden. Knowledge of effective interventions, and their accompanying implementation strategies, needs to be generated and synthesised (eg, in Cochrane reviews), as has been the case for falls prevention for some time.31 The power of this Cochrane and other systematic reviews of evidence to directly underpin policy decisions cannot be overstated, yet they are not common in sports medicine. The power of active collaborations with policy makers and investment of research effort in developing realistic cost–benefit estimates for both different preventive actions as well as the costs of inaction have also been demonstrated for falls prevention in older people.32,,34 Other successful injury prevention information strategies have including the development and validation of injury indicators that could also be used to monitor policy need and success over time.14 15 35

Conclusions

SIP public health policy prioritisation and development is a two-way process and it is critical that the right people are engaged in the consultations from the outset. Health departments are constantly under pressure to respond to competing priorities. Although physical activity promotion and obesity prevention are on government health departments' agendas, SIP does not yet rank highly because of its relatively quiet voice and the fact that there is very little hard evidence to support claims for its priority ranking, the existence of solutions and likely cost-savings to government health departments.

It may be obvious to sports medicine professionals that government health departments have a role in SIP, but they do not have the direct skills, focus or imperatives to actually intervene in sports settings. For this reason, it is important that both groups begin to become engaged in efforts to integrate governmental action across portfolios (eg, sport and health).15 For example, government health departments can do nothing about how sport is delivered, how coaches are educated, how rules and regulations in sport are set or in directly encouraging players to undertake specific neuromuscular training programs. All of these actions, more rightly, sit under the umbrella of government sport departments and their agencies. Nonetheless, a significant barrier towards development of macro-level sports safety policy has been identified as a discrepancy between what different government sectors see as their problem and what others expect of this.5 Much more work needs to be done to overcome this perception, and answering the questions posed in table 1 would be a significant step towards this.

Finally, efforts to get SIP onto public health agendas have been hampered to date because of the lack of direct communication between sports medicine and public health professionals and agencies. When attempts have been made, they have suffered from a lack of common understanding of the problem and its implications and a lack of data to support the sports medicine position. It is possible that sports medicine will need to embrace a new language when engaging with government health department officials. But one thing is very clear, unless the sports medicine sector fully engages in this new dialogue, SIP will continue to be left off the public health agenda.

References

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Footnotes

  • Competing interests None.

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

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