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Abstract
Objective To identify changes in International Federations’ priorities and the barriers to implementing athlete and global health initiatives. Results should influence the work of the International Federation medical committees, the IOC and the Association of Summer Olympic International Federation.
Methods The 28 Summer and 7 Winter International Federations participating in the most recent Olympic Games (2016; 2018) were surveyed to (i) identify the importance of 27 health topics, (ii) assess their progress on implementation health-related programmes and (iii) the barriers to implementation of these programmes. We compared International Federations’ activities in 2016 and 2017.
Results The response rate was 83%. Health topics which most International Federations regarded as important and in which the International Federations felt insufficiently active were ‘team physician certification’, ‘prevention of harassment and abuse’, ‘eating disorders/disordered eating’, ‘mental health’ and ‘injury surveillance’. Compared with 2016, there was a decrease in International Federations’ activities in ‘injury surveillance’, ‘nutritional supplements’ and ‘hyperandrogenism’. The main barrier to implementing health-related programmes was ‘International Federation political support/willingness’, followed by ‘knowledge’. ‘Time’ and ‘coach support’ were more often reported than ‘finances’, or ‘IOC or Association of Summer Olympic International Federations partnership’.
Conclusion If International Federations are going to promote health of athletes and global health promotion through physical activity (sport), International Federation leadership must change their focus and provide greater political support for related initiatives. Improving coach and athlete knowledge of the health issues could also facilitate health programme delivery. Time constraints could be mitigated by sharing experiences among the International Federations, Association of Summer Olympic International Federations and the IOC. International Federations should focus on those health-related topics that they identified as being important, yet rate as having insufficient activity.
- elite athletes
- health promotion
- prevention
- sports injury
- knowledge transfer
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Introduction
As defined in the Athletes Rights and Responsibilities Declaration approved by the IOC in October 2018, athletes have 12 ‘rights’ and 10 ‘responsibilities’. One of the athletes’ rights in the Declaration is:
7. ‘The protection of mental and physical health, including a safe competition and training environment and protection from abuse and harassment'. 1
This Athlete Right is the underlying fundamental principle of the work of the Medical Commissions of the International Federations (IF), the IOC and the Association of Summer Olympic International Federations (ASOIF). The role of the IFs in protecting athlete health is also embedded in the Olympic Movement Medical Code2 and the Olympic Charter (Article 26–1.8).3 Athlete health protection is the responsibility of everyone involved in elite sport.4
Research has been published previously on the priorities and activities of the IFs on the promotion of athlete health.5–7 Mountjoy and Junge5 concluded that the IFs’ highest health priority was the ‘fight against doping’ followed by the ‘health of their elite athlete’ and ‘image as a safe sport’. Little importance was given to the ‘health of recreational athletes’ and ‘health of the general population’ through promotion of physical activity (sport). A follow-up survey of the IFs’ health priorities and activities was completed in 2016, and a comparison of results demonstrated a decrease in attention to their role in promoting global health through sport.6 Finch et al 7 concluded that IFs valued research that is practical, for example, how to best implement injury/illness prevention strategies, and how to determine the effectiveness of these strategies. This type of research was classified as stage 5 and 6 of the Translating Research into Prevention Practice (TRIPP) Framework.8 9 In contrast however, the IOC Research Centres10 focused their research priorities on the determination of the prevalence of athlete injury and illness and the underlying mechanisms; classified as stage 1 and 2 of the TRIPP Framework.7 This finding represented the different focus of the IFs in comparison with the IOC Research Centres demonstrating the importance of understanding the differing social contexts and opportunities between these two groups. In order to effectively protect athlete health, knowledge of the realities of the IFs who are applying the science in the real world is important. What remains unknown is the determination of the specific social contexts that drive IF health priorities, programme development and activities and in particular, what are the barriers to implementing programmes to protect athlete health and to promote physical activity through sport to improve global health.
The objectives of this study therefore were (i) to identify the changes in IFs’ prioritisation and activities of athlete and global health-related topics, and (ii) to determine the barriers to the implementation of these initiatives. The purpose of this study is to inform and influence the work of the IF medical committees, the IOC and the ASOIF with the ultimate goal to improve athlete health.
Methods
All 35 IFs participating in the Summer and Winter Olympic Games (OG) 2016/2018 (table 1) were contacted by the chair of the ASOIF Medical and Scientific Consultative Group via email requesting their cooperation to complete an online survey. The survey was addressed to the Secretary General/Executive Director of each IF with a copy to the Chair of the IF Sports Medicine Committee. Following an introductory note, the survey requested identifying data and contact information to ensure the validity of the respondent and to allow follow-up for clarification as needed.
Characteristics of International Sports Federations (IFs) participating in the Olympic Games (OG) in 2016 and 2018
The participants were then asked up to three questions for each of 27 health topics that were chosen by the authors following a review of the sport medicine literature relevant to elite athlete health and were provided with an open option to specify other topics (table 2). The first question was: ‘From a medical perspective, how important is health topic for your sport?’ If they answered ‘not important’ or ‘low importance’, the question was repeated for the next health topic. If they selected ‘very important’ or ‘important’, they were asked the second question: ‘Are the activities of your IF with regard to health topic sufficient?’ If they answered ‘fully sufficient’ or ‘mostly sufficient’, they were asked the first question for the next health topic. If the answered ‘less sufficient’ or ‘not sufficient’, they were asked the third question: ‘What would help to improve your IF’s activities with regard to health topic? Please rank the three most important aspects in the order of importance’. The options were: ‘knowledge’, ‘skills’, ‘IF political support/willingness’, ‘finance’, ‘time’, ‘ASOIF partnership’, ‘IOC partnership’, ‘athlete support’, ‘coach support’, ‘other’.
Summary of the barriers to the implementation of IF athlete and global health programmes in response to the question: What would help to improve your IF’s activities with regard to health topic?
The IFs were given 4 weeks to respond, then email reminders were sent to encourage participation. Confidentiality of the data was maintained through the use of a password-protected access link and a research data storage system created by the University of Guelph, Canada. Details on the characteristics of the 35 IFs were gathered from the IOC website and the homepages of the IFs as well as from the publications of injury surveillance study during the OG in 201411 and 201612 (table 1). The results were compared with the 2016 survey.6 Data were processed using Excel and SPSS. Statistical methods applied were frequencies, cross-tabulations and χ2 test. Significance was accepted at p<0.05.
Results
The medical representatives of 29 IFs (22 summer and all 7 winter sports) completed the survey (response rate: 82.9%).
Importance of health topics
The ratings of the perceived importance of the 27 indicated topics of the individual IFs are presented in figure 1. ‘First aid minimum standards at events’ and ‘nutrition/hydration’ were rated ‘very important’ or ‘important’ by all IFs, ‘injury surveillance during IF championships/events’ by all IFs except one. More than 80% of IFs reported also ‘injury prevention by regulation for equipment/venues’, ‘rule changes based on sport-specific sciences’, ‘medical licensing at IF championships/events’, ‘protection of the athlete from harassment and abuse’ and ‘rest days between competitions’ as important in their sport. Less than 50% of the IFs regarded ‘relative energy deficiency in sport (RED-S)’, ‘technology-based health risk’, ‘disorders of sexual development (hyperandrogenism)’ and ‘training/competing during pregnancy’ as important. Twelve IFs listed additional important health topics including: psychological growth problems; health issues which become apparent through the athlete biological passport; chronic ankle and knee instability; communicable diseases that cannot be checked by team doctors (eg, AIDS); concussion and helmets requirements; safe prize money giving protocols; recreational drug abuse/alcohol consumption at events; exercise is medicine; hygiene, prevention of infectious disease transmission, travel, at venues and training camps; injuries in other sports using techniques of the Olympic Weightlifting (eg, CrossFit); long-term diseases due to rapid weight loss; muscle and tendon issues; school health promotion; smokeless tobacco; drugs and antidoping; prevention of eye diseases (myopia); competition calendar; young athletes physical/psychic development and health impact of the environment.
International Federation medical representative’s rating of importance of health topics.
Sufficiency of activities on health topics
The IF’s self-rating of the sufficiency of their health activities is presented in figure 2. Only for ‘first aid minimum standards at events’ all IFs reported to have sufficient activities. Furthermore, all IFs which regarded ‘injury prevention by regulation for equipment/venues’ as important, reported to have sufficient activities. More than 20 IFs (69.0%) have sufficient activities concerning ‘implementation of Olympic Movement Medical Code’, ‘rule changes based on sport-specific sciences’, ‘rest days between competition’ and ‘nutrition/hydration’, but >50% of IFs that regard the topic as important have insufficient activities in ‘team physician certification’ (13 of 23), ‘eating disorders/disordered eating’ (11 of 16), ‘prevention of chronic diseases in the general population’ (9 of 17), ‘RED-S’ (7 of 13), ‘disorders of sexual development (hyperandrogenism)’ (5 of 9).
International Federation medical representative’s rating of sufficiency of programmes for health topics identified as being important.
Sorting the health topics by the number of IFs reporting less or not sufficient activities in an important health topic (figure 3), it becomes apparent that more activities are especially needed for ‘team physician certification’ (n=13), ‘protection of athlete from harassment and abuse’ (n=12), ‘eating disorders/disordered eating’ (n=11), ‘mental health of athletes’ (n=11) and ‘injury surveillance during IF championship/events’ (n=10).
International Federation medical representative’s rating of sufficiency of programmes for health topics identified as being important (sorted by number of International Federations with less/not sufficient programmes).
Support needed to improve activities
In response to the question, ‘What would help to improve the IF’s activities with regard to important and insufficient health topics?’ ‘IF political support/willingness’ and ‘knowledge’ were the most frequent answers. ‘Time’ and ‘coach support’ were more often reported as a requirement than ‘finances’. However, the ranking varied substantially between the topics (table 2).
‘IF political support/willingness’ was named most frequently as the top requirement and among the three top requirements for ‘injury prevention by Fair Play campaigns’, ‘post elite career management’, ‘prevention of chronic diseases in the general population’ and ‘environmental conditions (eg, temperature, altitude)’. It was also most often rated as the top requirement for ‘preparticipation medical examination’ and ‘rest days between competitions’, and most frequently reported among the top three requirements for ‘protection of the athlete from harassment and abuse’, ‘athletes’ eligibility and return-to-play after injury’, ‘drug importation at IF championships/events’, ‘injury surveillance during IF championships/events’, ‘team physicians certification’, ‘medical licensing at IF championship/events’, ‘sport-specific concussion management’ and ‘technology-based health risk’.
‘Knowledge’ was reported as the top requirement and among all options for activities concerning ‘injury prevention by exercise-based programmes’, ‘mental health of athletes’, ‘eating disorders/disordered eating’, ‘age determination’, ‘nutritional supplements’, ‘technology-based health risk’ and ‘training/competing during pregnancy’. It was also chosen by the IF medical chairs as the leading requirement for ‘protection of the athlete from harassment and abuse’, ‘athletes’ eligibility and return-to-play after injury’, ‘sport-specific concussion management’, ‘nutrition/hydration’, ‘RED-S’, ‘disorders of sexual development (hyperandrogenism)’ and ‘drug importation at IF championships/events’, and most often among the three top requirements for ‘environmental conditions (eg, temperature, altitude)’.
‘Time’ was ranked most often as the first item required for ‘team physician certification’, ‘medical licensing at IF championship/events’, ‘implementation of the Olympic Movement Medical Code’, ‘drug importation at IF championships/events’ and ‘eating disorders/disordered eating’. It was most frequently chosen among the top three requirements for ‘implementation of the Olympic Movement Medical Code’, ‘medical licensing at IF championship/events’ and ‘preparticipation medical examination’.
‘Coach support’ was most frequently selected as the number one requirement for ‘RED-S’ and ‘sport-specific concussion management’. It was most frequently among the top three requirements for ‘RED-S’, ‘nutrition/hydration’, ‘eating disorders/disordered eating’, ‘rest days between competitions’ and ‘training/competing during pregnancy’.
‘Finance’ was chosen as the top requirement and among the three top requirements for ‘injury surveillance during IF championships/events’ and ‘rule changes based on sport-specific sciences’, respectively. It was also among the most frequently selected requirements for ‘environmental conditions (eg, temperature, altitude)’.
‘IOC partnership’ was listed among the three top requirements for only two topics: ‘implementation of the Olympic Movement Medical Code’ and ‘disorders of sexual development (hyperandrogenism)'. ‘ASOIF partnership’ was only listed among the three top requirements for ‘team physicians’ certification’.
Comparison of activities with a previous survey
As the health topics in the 2017 survey were the same as in 2016, a comparison of the IF’s activities is presented in figure 4. For about half of the topics (n=13), the percentage of IFs with activities was similar in 2016 and 2017, and for 11 topics the percentage of IFs increased. A substantial decrease of IFs’ activities was observed for ‘injury surveillance during IF championships/events’ (85%–62%), ‘nutritional supplements’ (52%–38%) and ‘disorders of sexual development (hyperandrogenism)’ (44%–14%).
Comparison of International Federation health-related activities in 2016 and 2017.
Discussion
Athlete health priorities and activities
As in the previous surveys (2012, 2016),5 6 the IFs prioritised topics related to IF event safety (‘first aid minimum standards at events’, ‘injury prevention by regulation for equipment/venues’ and ‘injury surveillance during IF championships/events’) and elite athlete health (‘nutrition/hydration’ and ‘preparticipation medical examination’). In comparing IF activities between 2016 and 2017, the IFs reported an increase in activities related to both IF event safety (‘medical licensing at IF championships’, ‘rest days between competition’ and ‘rule changes based on sport-specific sciences’) and elite athlete health (‘protection from harassment and abuse’, ‘mental health’ and ‘technology-based health risks’). These findings demonstrate that the IFs understand the importance of risk management in their sports.13
While it is encouraging to see the increase in health-related activities reported in this survey, it is important to note that IFs are not prioritising some athlete health-related topics which have been identified in the scientific literature as being important parameters of elite athlete health. For example, nutritional supplement utilisation by elite athletes has been identified as being prevalent and problematic from a health and antidoping perspective, thus prompting the IOC to publish a Consensus Statement on the topic in 201814. Despite the recent focus in the scientific literature, ‘nutritional supplements’ has substantially decreased in priority for the IF in comparison with the 2016 survey results (52%–38%). The reasons for these changes in priority were not ascertained in the current study. Another relevant athlete health topic that IFs are not prioritising is ‘RED-S’. The field of science in this area has expanded tremendously revealing a greater understanding of the underlying mechanisms as well as the prevalence in both male and female elite athletes. The IOC has also published a recent update Consensus Statement on this athlete health issue.15 The third topic of low priority for IFs is ‘eating disorders/disordered eating’. The prevalence of this mental health problem is well documented to be higher in elite athletes than in the general population, and published guidelines exist for the prevention, identification and treatment in elite athletes.16
The comparison of the current with the 2016 IF health activities survey has also demonstrated a substantial decrease in ‘injury surveillance during IF championships/events’ (85%–62%) and ‘disorders of sexual development (hyperandrogenism)’ (44%–14%). Given the emphasis by the IOC on injury and illness surveillance at the OG (eg, 2008,17 2010,18 2012,19 2014,11 2016,12 Youth Olympic Games 201620 and the publication of injury and illness surveillance by many IFs (eg, football,21 volleyball,22 skiing,23 gymnastics,24 aquatics,25 athletics,26 handball,27 rugby28 and ice hockey29), the decrease in activity in this area of athlete health was unexpected. In addition, the topic of hyperandrogenism has been prominent in the media recently with the recent Court of Arbitration of Sport decision30 and subsequent policy development of the IAAF.31 Although the prevalence of hyperandrogenism in elite sport is unpublished, it is unlikely that this issue is unique only to the sport of athletics.
A novel finding in this survey was the IF rating of the sufficiency of their programmes for various health topics. The results show that the IF medical representatives reported less/insufficient programs for a number of important, prioritised health-related topics including ‘team physician certification’,32 ‘protection of athlete from harassment and abuse’,33 ‘eating disorders/disordered eating’,16 ‘mental health of athletes’34 and ‘injury surveillance during IF championship/events’.4 Despite the fact that the IFs are aware of the importance of these topics, and that there is adequate content-related knowledge published in the scientific literature, the IFs self-report that their activities in these areas are insufficient. This finding demonstrates that barriers exist within the IF to the implementation of health programmes, particularly in these athlete health topics.
Barriers to health programme implementation
A novel outcome of this study is the identification of barriers to implementing IF health programmes. As indicated by the IF medical respondents of the survey, the IFs are aware of the need to address various topics related to athlete health, but have identified that some of their prioritised programmes are insufficient. The main barriers reported to implementing heath programmes were ‘IF political support/willingness’, ‘knowledge’, ‘time’ and ‘coach support’. A review paper looking at sports injury prevention implementation research by Finch35 identified that only a few studies in the field of sport medicine research evaluate the implementation phase of interventions to best understand the real-life sport context; including both the barriers and facilitators to implementation. The authors concluded with guidelines to improve the efficacy of sport medicine research, addressing a specific recommendation to identify the barriers to implementation within the complex reality of the sport culture and context.35 Another study by Bekker et al 36 on the translation of injury prevention and safety promotion knowledge, also supports the need for the identification of barriers and enablers to knowledge translation to improve health programme implementation.
IF political willingness/support
The most commonly identified barrier to the implementation of athlete and global health programmes was ‘IF political willingness/support'. Within the cultural context and political structure of international sport, the funding of health-related research, the implementation of intervention programmes and the ability to change the sport rules to improve safety are dependent on political support from the IF sport governing body. In a review paper on sport safety, Timpka et al 37 concluded that the future success of athlete safety is contingent on an intersection between epidemiological evidence from sport science research, the sport context and the processes by which policy change is made. Successes from the field of policy change in public health are based on the effective translation of epidemiological evidence to the implementation of public health policy change.37 The final key step identified in a framework of successful activation of policy change in public health by Davis et al 38 is to ‘consider the political and social environments; recognising that the strategy for implementing policy change is situational and iterative’. Hanson et al 39 have applied the public health model to the sport context. In order to close the research-to-practice gap, they also identify that policy makers are an integral part of the solution in collaboration with researchers. Within the sport medicine literature, a large systematic review of the efficacy of sport injury prevention by Klugl et al 40 found that only 4% (492 of 11 859) of all published studies in the review addressed implementation or intervention efficacy, and that only 2% examined the intervention within the context of the real-world situation. These authors concluded that ‘regulatory change’ is a key component for the success of injury prevention in sport.40
Based on the findings from this study, to effectively implement health programmes at the IF level, the IF medical leaders should become proficient in the ability to influence policy change of the political sport governing body. In addition, the ASOIF and the IOC should develop intervention opportunities and programmes directly targeting sport political leaders on the importance of investing in health. These interventions may help to influence and activate IF policy change and political support for health initiatives.
Knowledge and coach support
‘Knowledge’ and ‘coach support’ were the next frequently reported barriers to the implementation of IF health programmes. Numerous publications in the areas of elite athlete and global health topics exist in the scientific literature. To address the barrier of lack of knowledge, IF medical committees can participate in a variety of educational opportunities including advanced academic training (eg, FIFA Diploma,41 IOC Sports Medicine Diploma,42 IOC Advanced Team Physician Course43) or through attending international sport medicine conferences (eg, IOC World Injury and Illness Prevention Conference,44 FIMS World Congress of Sports Medicine45).
However, knowledge alone is insufficient in realising successful implementation of athlete and global health initiatives. Hanson et al 46 postulate that a combination of three groups of experts is required for successful programme outcomes: content experts (researchers), process experts (clinicians and policy makers) and context experts (members of the target community). In this model, coaches represent the ‘context experts’. The IF medical respondents to this survey supported this finding in identifying that a barrier to successful implementation of athlete health programmes is ‘coach support’. This finding should stimulate the development of IF knowledge translation opportunities combining coaches with sport medicine clinicians and sport scientists. For example, the Fédération Internationale de Natation (FINA) (aquatic sports) has developed a knowledge translation opportunity by combining the biannual FINA World Golden Coaches Clinic with the FINA World Sport Medicine Congress. The programme is designed with an entire day of overlap of joint programming dedicated to various athlete-related health topics. The target audience for this specialised day is coaches, scientific research experts and sport medicine physicians.47 48
Time and financial support
As almost all IF Medical Committees comprise politically appointed volunteer clinicians, it is not surprising that ‘time’ was identified as a barrier to programme implementation in this survey. For volunteer clinicians, time is limited to conduct research, develop prevention interventions, advocate for policy change and evaluate programme efficacy. The barrier of ‘time’ could be easily addressed by the hiring of a full time IF sport medicine and/or sport science expert. This change in structure from a volunteer to a funded basis would require a change in the culture of the IF to prioritise athlete and global health, as well providing both political and financial support. A successful example of this was the FIFA-Medical Assessment and Research Centre programme,49–51 which conducted research on various aspects of health of football players for >20 years. For those IF whose financial reality precludes the hiring of a full time health expert, the barrier of ‘time’ could be mitigated through collaboration with other IFs, ASOIF and the IOC.
An unexpected finding of this survey was the low ranking of ‘financial support’ as a barrier for athlete and global health programme implementation. ‘Financial support’ was identified by the IFs as a barrier for the implementation of injury and illness surveillance. This finding was also surprising, as injury and illness surveillance is not expensive to implement.
Global health priority and programmes
It is well known that physical inactivity is an independent risk factor for the development of non-communicable diseases (NCD). Participation in regular physical activity has been proven effective in treating and preventing NCDs, such as diabetes, stroke, heart disease and some cancers. It also prevents obesity, hypertension and improves mental health as well as quality of life.52 Despite the well-known importance of the role of physical activity in health, a study of 1.9 million participants from 196 countries representing 96% of the world’s population, revealed that 1 in 4 adults (27.5%) do not meet the WHO’s recommended levels of physical activity. This statistic has remained unchanged since the early 2000, and indicates that the WHO goal of a 10% reduction of physical inactivity levels by 2025 is not on target.53 In some high-income countries, levels of physical inactivity can reach as high as 70%.54 The cost of physical inactivity to health systems are estimated globally to be US$54 billion in direct healthcare (2013 data) comprising 1%–3% of all national healthcare expenditures. In addition to direct healthcare costs, a further cost to society from physical inactivity is approximately US$14 billion from lost productivity.54
In the 2018 Global Action Plan on Physical Activity, WHO identified sport as an ‘underused yet important contributor to physical activity for people of all ages…[and as] a catalyst and inspiration for participation in physical activity—access to sport and quality physical education is a fundamental right for all’.54 IFs, as a member of the Olympic Movement, have the obligation to develop ‘sport for all’ as outlined in the Olympic Agenda 2020,55 Recommendation #51 of the Olympic Movement in Society Congress (Copenhagen 2009)56 and in the IOC Consensus Statement on the Fitness and Health of Young People.57
In the 2016 IF survey, the most disturbing finding was the statistically significant decrease in IF priority of the ‘health of the general population’ between 2012 and 20166. In response to this finding, the 2016 IF Forum ‘The Power of Sport to Drive World Health’ focused on the importance of global health promotion through sport.6 Although it is encouraging that more IFs reported activities in global health promotion in this present study than in 2016, only 8 (47.1%) of the 17 IFs that rated the ‘prevention of chronic diseases in the general population’ as being either very important or important regarded their programmes as being sufficient. This finding demonstrates that IFs have acquired the knowledge that they should be active in NCD prevention through the promotion of physical activity in the global population, but they have had limited success in implementing physical activity promotion through sport programmes. Identification of the barriers and challenges to implementation is essential to facilitate programme success.
Study limitations
As with any survey methodology, there is an inherent risk of self-report bias. The self-report bias was mitigated by ensuring anonymity of the IF in the publication and confidentiality of all data. Given the study design, verification of the quality or reported programmes was beyond the scope of the study.
Application of findings
In response to the lessons learnt from this survey, the ASOIF Science and Medical Consultative Group decided to partner with the IOC Medical and Scientific Department to address some of the identified gaps via a dedicated workshop in December 2018 in Lausanne at the IOC headquarters. The workshop commenced with a presentation of the results of this study to set the scene. This was followed by an educational session on change theory with practical guidelines on implementing change within the social context of the International Sport Federation milieu. The remainder of the 1.5-day workshop was dedicated to five health topics: (i) injury and illness surveillance; (ii) prevention of harassment and abuse in sport; (iii) athlete mental health; (iv) effective OG healthcare delivery and (v) the promotion of physical activity through sport to improve global health. Following a brief educational introduction, the IF and IOC medical representatives participated in an interactive workshop exploring the application of change theory for the development of a strategy for programming for each respective athlete health topic. The promotion of global health through physical activity (sport) built on the Declaration from the IF Forum (2016).6
‘We, the International Federations, recognise and acknowledge our responsibility to promote health; for our athletes and for the global population. Through collaborative action, and partnerships with non-sport entities, we will develop, implement and evaluate the effectiveness of programmes to promote health through the power of sport’ and the Action Plan identified by the IFs in the 2017 ASOIF workshop.6 The overarching objective of the workshop was for each IF medical representative to leave the workshop with the skills to implement change in their respective IF by addressing the identified barriers and taking into consideration the political and social context.
Conclusion
The IFs participating in the Summer and Winter OG 2016/2018 were aware of their responsibility to protect the health of their athletes, as evident by the improved prioritisation of several of the athlete health related topics in this study. Despite the improvement in prioritisation of these topics in the interim time interval since the previous survey, there has been a significant decrease in the prioritisation of other important athlete health-related topics. In addition, the IFs have identified insufficient activity in many areas of athlete health. The IFs have the ethical responsibility to protect athlete health and should prioritise and implement efficacious programmes to address all aspects of athlete health to protect the health of their athletes, and to improve athlete performance and retention in sport.
While it is encouraging to see an improvement in the prioritisation of global health through the promotion of physical activity, it was disturbing to find that less than half of these IF had sufficient programmes. IFs can play an important role in promoting physical activity and thus have a moral obligation to respond to the global health epidemic of NCDs by adapting and marketing their sport to improve global health. The secondary benefits of investing in global health initiatives could be an increase in fan-base as well as a deeper athlete talent pool.
The identification of the barriers to IF health promotion is a novel finding of this study. The facilitation of IF activities to promote athlete and global health requires a change in emphasis of the IF leadership to address the barrier of IF political support. Improving the knowledge base of coaches and sport medicine clinicians of the relevant athlete health-related issues could also improve the efficacy of athlete health-related interventions. Time constraints could be mitigated through the addition of a sport medicine and/or sport scientist expert to the staff of the IF, or through the sharing of resources and expertise via collaboration with other IFs, ASOIF and the IOC.
IFs are influential in driving policy change and actions of their member National Federations. Addressing the gaps and barriers in IF athlete and global health programming identified in this study should result in a ‘trickle down’ effect at the National and Club levels. Application of the findings of this survey should inform and influence the activities of the IOC Medical Commission and the ASOIF Medical and Scientific Consultative Group to help the IFs mitigate the identified gaps and barriers to implementation of health programmes, which will ultimately realise improved athlete health outcomes, sport performance and global health.
What are the findings?
International Sport Federations (IFs) are aware of, and prioritising many aspects of elite athlete health.
However, IFs have identified important health topics that are not being attended to.
These come with potential reputational risk to the IFs.
IFs identified political support/willingness within their own organisation as the main barrier to implementing health programmes.
Lack of knowledge (how and what to do) and lack of time (priority) were other barriers the IFs cited.
Although IFs have increased activities in many health topics, important health topics have seen a recent decrease in IF activity relative to other topics, including athlete injury surveillance, abuse of nutritional supplements and hyperandrogenism.
How might it impact on clinical practice in the future?
Those who serve on IF sport medicine committees should obtain competency in political lobbying, project management and change theory.
Effective evidence-based knowledge translation on elite athlete health issues and the promotion of sport (physical activity) for global health is required for members of IF sport medicine committee members.
Evidence-based, coach-focussed education to enhance coaches’ knowledge of athlete healthcare was identified by the IFs as important to advance athlete health education and research programmes in IFs.
Acknowledgments
The authors would like to thank the political support of Association of Summer Olympic International Federations (ASOIF) for the implementation of the survey and the subsequent IF Workshop held in Lausanne, November 2017. The authors would like to thank Tony Pfaff of the Health and Performance Centre, University of Guelph for the logistical support of the survey. The authors would also like to thank medical representatives of the International Federations who shared their experiences through this survey, thus providing the data for this project.
References
Footnotes
Contributors MM: first author, substantial contributions to conception and design, data collection, interpretation of results, drafting and revising the manuscript and final version to be published. AJ: second author, substantial contributions to conception and design, data analysis, interpretation of results, drafting and revising the manuscript and final version to be published. RB, DD, ML, SM, JM, JF: substantial contributions to data collection, revising the manuscript and approval of final version to be published.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Ethics approval Formal Research Ethical Board approval was sought but not required for this study.
Provenance and peer review Not commissioned; externally peer reviewed.
Patient consent for publication Not required.