How do coaches talk about tackling? using the theory of planned behavior to explore coach communication with youth football and soccer players about physical contact in sport

Abstract

Physical contact such as tackling is a part of youth sport, but associated with concussion risk. Coach communication with athletes about how to approach contact could be a strategy to reduce concussion risk. We interviewed n = 50 adult stakeholders (coaches, referees and administrators) in youth football and soccer to identify barriers and facilitators to coach communication about contact. We framed interviews using the Theory of Planned Behavior, discussing: knowledge/experience, attitudes/beliefs, norms/values and perceived behavioral control. Stakeholders could easily describe ‘good’ contact (knowledge/experience) like keeping your head up (football) and tackling shoulder-to-shoulder (soccer), and ‘bad’ contact like spearing (football) and retaliating against an opponent (soccer). They also talked about the importance of sportsmanship and playing by the rules. Most coaches believed ‘bad’ contact was associated with greater injury (attitudes/beliefs). Coaches felt responsible for managing contact (norms/values), but also described not receiving any information indicating that this was part of their role. Coaches worried about creating a fear of injury, and felt it was important for discussions to be framed positively (perceived behavioral control). In summary, youth football and soccer coaches believe ‘bad’ contact is associated with greater injury risk and feel it is their role to provide youth guidance about contact, but describe a lack of institutional guidance regarding this role. They also are concerned about barriers, including creating fear, and describe ways to address this barrier with language. Developing programs to support coach communication about contact with youth athletes presents a potential strategy for concussion prevention.

KEY MESSAGES

• Youth football and soccer coaches know that some contact (like head-to-head tackling) is associated with greater risk of injury, particularly concussion.

• Coaches feel responsible for teaching youth approaches to tackling and other sport contact that have a lower risk for injury, but most are not provided guidelines for how to do this.

• Coaches feel it is important to frame messaging positively, e.g. ‘lead with your shoulders’ rather than ‘keep your head down’.

• Instructing coaches regarding how to teach ‘good’ contact in sport is a potential strategy for injury prevention.

Keywords:

• Brain concussion
• health communication
• qualitative research
• youth sports
• theory of planned behavior

Reviewing Editor:

• Joe Homas
• Institute of Health and Management
• Australia

SUBJECT:

• sports coaching
• risk communication
• health communication
• health & society
• public health policy and practice

Introduction

More than 44 million U.S. youth 6 to 17 years old participate in organized sports (Langhorst, 2016). While sports provide opportunities for social connection, physical activity and skill development (Eime et al., 2013), participation in sports is also associated with risk of injury, particularly concussion (Howell et al., 2020). Sports that involve routine contact and collision pose the greatest risk for concussion, with soccer being one of the most popular contact sports worldwide and football (i.e. American football) yielding some of the highest rates of injury (Marshall et al., 2015). Sustaining a concussion in sport can in turn have significant impacts on all aspects of youth development, impacting academics, social interaction and emotional state (Voormolen et al., 2019). It is thus vital that we work to mitigate concussion risk in youth sport.

Previous work to decrease concussion risk in sport has focused on increasing identification of concussion in youth through both legislation (Yang et al., 2021) and educational interventions designed to increase reporting (Kroshus et al., 2015, 2018; Register-Mihalik et al., 2013). However, these approaches at best result in secondary prevention–-mitigating the potential risk of an injury after it has occurred, or decreasing concussion morbidity. From a public health standpoint, we believe in the importance of primary prevention of concussion, or decreasing concussion incidence (Emery & Pasanen, 2019). Prior work regarding on-field measurement of biomechanics suggests that for a concussion to occur, an athlete must sustain a collision of sufficient magnitude with either another player, the ground or an object (Guskiewicz & Mihalik, 2011). There are thus two pathways towards decreasing concussion incidence in sports: (1) decreasing collisions and (2) mitigating the force of those collisions. The majority of sports-related concussions occur due to collisions between players (Maher et al., 2014; Willigenburg et al., 2016), and certain types of collisions have been found to be associated with greater risk for concussive injury, such as head to head contact in football (i.e. spearing) and body checking in ice hockey. Rules limiting those types of activities in youth sports have resulted in fewer injuries (Black et al., 2016, 2017; Emery et al., 2010; Obana et al., 2021; Warsh et al., 2009). USA Football (an organization that oversees U.S. football leagues) developed an injury prevention program based on limiting inappropriate or potentially injurious contact in youth called Heads Up Football®, with evidence suggesting benefit for this approach (Kerr et al., 2016, 2017; Shanley et al., 2021; Tokish et al., 2017). Heads Up Football® teaches youth to tackle in football by leading with the shoulder rather than the head, and also incorporates monitoring and feedback with a goal of decreasing injury. However, Heads Up Football® is not widely available and is associated with a cost, and thus many football leagues or schools do not currently utilize this approach.

Recognizing the need for accessible approaches to primary prevention of concussion in youth sports, we decided to explore how coaches think about and discuss physical contact and injury risk with youth athletes. Providing guidance to youth athletes about the relationship between types of contact and injury risk has the potential to reduce dangerous collisions, thereby decreasing injuries in youth sports. Coaches are in an ideal position to communicate this type of information to youth athletes, as a trusted adult supporting safe youth participation in the sport. However, little is known about whether and how coaches engage in these types of dialogues, and factors that influence these discussions. We undertook this study to fill this gap in the extant literature, interviewing coaches and other key stakeholders in youth football and soccer to understand the coach role in managing youth athlete contact, and barriers and facilitators to having discussions about contact with youth athletes. We then analyzed these interviews to develop a conceptual model regarding factors influencing coach discussions about contact, adapting the Theory of Planned Behavior (Ajzen, 1991).

Materials and methods

Study design and research personnel

The sample for this study is a subset of that used for a previous study (Chrisman et al., 2022). In order to obtain a more diverse sample that would increase generalizability, we undertook these discussions with participants from two geographic regions: 1) Western Washington and 2) Southern Georgia. In brief, we completed qualitative interviews from 2019–20 with coaches, referees and field administrators from youth football and soccer leagues (Kroshus & Chrisman, 2019). We conducted rigorous data collection and analysis and this report conforms to the Standards for Reporting Qualitative Research (O’Brien et al., 2014). The research team included a pediatrician and health services researcher (SC), a public health researcher (EK), a medical anthropologist (KS), a health communications researcher (BB), a professor of athletic training (TH), a research coordinator (RH) and five clinical research associates with backgrounds in exercise science, sport psychology and athletic training (EK, NW, SW, KH, MM). Data were collected and analyzed by RH, TH and the research associates who were trained in qualitative interviewing, codebook development, coding and synthesis by KS who supervised the activities. Interviewers and interviewees were culturally and ethnically congruent as much as possible. Team members had experience with sport culture as athletes, coaches or athletic trainers, and conducted interviews in their own region given the cultural differences between Southern Georgia and Western Washington.

Data tools

We designed an interview guide as a team and adjusted as necessary per standard qualitative methodology (Patton, 2015). Interviewees first answered a few demographic questions, and then more extensive qualitative questions (see Appendix for full interview guide). Topic areas for the qualitative interviews were developed using the frame of the Theory of Planned Behavior (TPB) (Ajzen, 1991), a theory of behavior which highlights factors thought to influence the likelihood of a certain behavior (in this case, stakeholder communication about contact and injury risk in sport), particularly: Knowledge/experience, Attitudes/beliefs, Norms/values and Perceived Behavioral Control. We utilized open-ended questions to discuss physical contact and injury risk in sport, focusing on these key constructs from TPB.

Sampling frame and data collection

We recruited a purposive sample of youth soccer and football coaches, referees and administrative staff from Southern Georgia and Western Washington (n = 27 from Western Washington and n = 23 from Southern Georgia). Recruitment occurred via phone call, email and/or text, and interviews took place over the phone or in person (at a convenient location such as a coffee shop or community center). Interviews were digitally recorded, professionally transcribed verbatim, and spot checked to ensure data integrity. Every effort was made to maintain participants’ confidentiality during data collection and manuscript preparation. All audio files were destroyed immediately following transcription. Participants provided written consent and were provided an incentive for their time (US$40). The Seattle Children’s Research Institute Institutional Review Board and Georgia Southern University Institutional Review Board approved all study procedures.

Analysis

Data were analyzed using Dedoose version 7.0.23 (Dedoose, 2018) for coding and thematic content analysis (Bazeley, 2013) following procedures outlined by Braun and Clark (Braun & Clarke, 2006). We developed a hierarchical codebook based on the Theory of Planned Behavior (Ajzen, 1991) and data review. Initial codes were derived from study goals and the interview guide, but codes were adapted and augmented based on review of five transcripts. New codes were tested on two additional transcripts by all coders and discrepancies were resolved by discussion. The codebook continued to be edited in this fashion until an exhaustive but manageable code list was reached. Transcripts were then open-coded using the final version of the codebook, by at least two coders, preferably including the individual who conducted the interview. Coders utilized a process of memoing to document decision points and assure transparency in interpretation and analysis. Coders were blind to each other’s coding and all differences were resolved by discussion until 100% agreement was reached. When necessary, the codebook was modified to accommodate new codes or definitions. Each code report was synthesized by one analyst using a system of annotating and summarizing into theme domains and subdomains with associated quotes. All steps of the analysis were overseen and guided by KS. Demographic data were compiled and tabled using Stata version 14 (Statacorp, 2015).

Table 2. Qualitative themes and representative quotes from an interview study about physical contact in sport with youth coaches, referees and administrators, 2019–2020.

Domain	Football	Soccer
Knowledge/experience
Knowing the difference between good and bad contact	Good contact is: Heads-Up tackling, using shoulders, wrapping up, using core to lift and drive and blocking, playing in a sportsman-like way Hitting hard. Football’s a tough game. It’s a physical game. And so, I want my kids to hit as hard as they can, but properly. I might tell them, take their head off. But at the same time, I don’t mean –not knocking the helmet because not only can you make them have a concussion, but you can have a concussion yourself. So, when I say, take their head off or hit them hard, I mean in a safe sportsmanlike way. So, that’s the main thing. [GF1] Well, at a basic level, anything that gets the other player to the ground, but I would say shoulder tackling, leading with your shoulder and not your head. And having a target zone between the hip and the shoulder. So, we’re not going at knees. We’re not going at heads. You know, a good square contact, wrap and drive. [WF1] Bad contact is: targeting/spearing, leading with the head, hitting too high or low, late hits, blindside blocks, chop blocks, helmet to helmet, fighting Intention is a factor in determining good vs. bad	Good contact is: playing the ball—not the person, shoulder-to-shoulder, playing by the rules I think if you need a definition in terms of a clean challenge, it’s like going in with an attempt to win the ball not to hurt the player. [WS1] GS uses strong physicality terms like pushing, body checking, hip-to-hip as well as shoulder-to-shoulder for good contact whereas WS talks about shoulder-to-shoulder and controlled play as being good contact. It’s part of the game to knock the other person off balance. You’re not trying to knock them into the fence. You’re trying to make sure that you get to the ball before they do, but that’s 100% physical contact. [GS2] Bad contact is: pushing, kicking, tripping, arms extended, fighting Some contact is not technically within the rules but is accepted by referees Referees set expectations around bad contact but not all referees manage the same way So, there are grey areas in the rules where, I mean, you can use your arms to help with your play, but should you? No, because again it just can escalate. And if you escalate from not using your arms at all to using your arms a little, it’s a lot better than from using your arms a little to using your arms a lot. [GS6] Intention is an important factor in determining good vs. bad I draw the line at intent If you can see, when you’ve coached awhile, a player’s that got intent, intent to injury –And there’s plenty of it about. And if you watch a pro game, you’ll see there’s sometimes an intent to it. So, that’s when you see a little bit more force. The ball becomes less of the issue as opposed to the contact. So, the contact’s a priority, as opposed to going for the ball. A fair tackle is both players going to the ball. When one player decides, ‘I’m going to have a little bit more intent to injure’, the ball becomes secondary, and you can see it. You can see it with how they line up before, and how they go through the contact. [GS7]
…but	Bad contact can result from lack of coordination, attention, bad technique, playing after whistle, anger/retaliation I feel like in my opinion, yeah, bad contact would be using bad form, and sometimes, it just happens. The kid doesn’t know any better, so he’s just got bad form, but I feel like sometimes if they have a purpose to or an intent to try –which some kids they’re not trying to hurt somebody, but then there’s that line where some kids are out there, and they got mad or really wanna hurt somebody, so that could be part of the bad contact. And then, sometimes it just happens, and there’s bad illegal contact here, illegal contact.[GF2] Even with proper form, bad contact can happen Plays will happen. You can have the perfect proper form and you’ll have bad contact because the ball carrier turns a different way, or it just so happens somebody gets –you get hung up on somebody and your head goes down and hits the turf first. [WF6] Tackling people of different age/size can be acceptable with good fundamentals Football is all about contact; it cannot be avoided but must be anticipated Football is contact, no matter what position you are, except maybe a kicker and a punter. [WF2] Football is inherently ‘violent’ and may or may not result in injury depending on individual behavior It’s a violent contact sport, so you need to understand that there is, I guess, a little bit of leeway there because you’re gonna get your bell rung at some point in your career. [GF5] It’s created to be a physical sport. It’s created to be a violent sport. But you can go through a whole career and not get injured. [WF2]	Bad contact can result from poor timing (late tackling), lack of coordination, playing the player instead of the ball, bad aerial challenges, slide tackling Good contact can still result in injury There’s a lot of legal physical contact that happens in soccer. A lot of people that don’t really play don’t really know that. But it is a physical game, and you have to be willing to be physical. [WS2] Difference in player size can result in bad contact Much larger player does a shoulder charge on the smaller player, while the smaller player’s both feet are in the air and knocks him on the ground without an attempt to play the ball. Technically, it’s legal, but some refs would probably blow a foul, and some refs wouldn’t because it’s kinda like –it’s in the gray area of the FIFA rules. [WS5] Aggression is an important component of soccer contact Be aggressive but make sure that you keep your arms close to your body and try to keep good balance. [WS6] We use aggression – aggression isn’t attacking the player. What aggression is – what we like to say is attacking the ball. [WS7]
Attitudes/beliefs
Bad contact is more likely to cause injury	Injuries result from lowering head to tackle, blindside blocks, intent to injure, hitting players after the whistle, helmet-to-helmet Especially using the crown of their helmet, which has caused a lot of concussions and a lot of injuries that I’ve seen over the years, even my own experience with playing football. [WF3] Bad PC can be intentionally injurious including cheap shots: trying to hurt others, hitting defenseless player or after play ends, reckless play, improper tackling Some players get hurt after the refs blow the whistle, and somebody gets a cheap shot in. [GF6] Not playing within the rules risks injury That will cost you an injury or somebody else getting injured and really getting them to understand the importance of playing within the lines. And if you step out of line, then there’s consequences and repercussions for that that could be severe up towards someone maybe dying for instance or getting severely hurt. [WF7]	Injuries result from heading, slide tackling, reckless play, and intent to injure Bad contact can be intentionally injurious including cheap shots: aggressive fouls, anger-fueled retaliation, poor technique I think it seems to me, particularly with the age I coach, that when anger comes into play, then I think that increases that testosterone and the power behind the physical contact, and that’s when I personally see injury occur. [GS1]
…but	Even unintentional bad contact can result in injuries because players are uncoordinated, lack spatial awareness, don’t know own strength And, again, certain players –there’s just kids that –there’s so much growth between sixth and eighth grade and just understanding who’s got the speed and who’s got the power. And those are the players that are gonna hurt half the team. [WF4]	Even unintentional bad contact can result in injuries because players are uncoordinated, lack spatial awareness, are reckless With slide tackling, if not done properly, 1.) You can hurt yourself, 2.) You can really hurt the other player as well because if you don’t get the ball, 9 times out of 10, your cleat is gonna hit the other player. [GS8] Referees are important; they enforce rules before injuries occur and stop play when injuries happen If you let a game go and the kids start getting more and more aggressive, that’s when the injuries –whether it’s knees or anything, it can occur more often, if you let it go. [GS4] Coaches and referees are responsible for managing behavior before intentional injury happens when aggression is escalating Because if they’re not getting the calls when these people are being so rough with them, they’re gonna be even rougher back. [GS8]
Norms/ values
Everyone is responsible for managing player contact	All coaches are responsible for correcting bad contact and teaching good technique Coaches are motivated to manage contact by: penalties, wanting players healthy on game day I think it depends on the coach. I think some do a great job of being more aware of it. I think some are just kind of ‘if it happens, it happens’, and if it’s a penalty, they may do something about it, but it may not be because of the safety thing. [GF7]	Management may include correcting bad contact or removing player from game if they are too emotional Some coaches are more focused on encouraging good contact and avoid talking about bad contact I don’t think a lot of coaches are out there saying, ‘Hey, make sure you don’t hit this player’. Or, ‘Make sure that you don’t tackle someone badly’. I don’t think a lot of coaches are saying that. They’re more going out there and telling their players that, ‘Hey, be aggressive, play hard’. [GS10]
…but	A handful of coaches do not manage contact and may even encourage bad contact There’s some programs that –and I can’t say this for sure, but some of the programs have had a little bit of that ‘play dirty’ rep for a while and it’s amazing how that continued to come out over the years. So, I think it’s a mixed bag. I think some coaches are real concerned about it. I saw it with how the talks were handled and I thought back and I reflected. [WF4] I've coached with and against some real, real ignorant idiots. I coached with a lot of guys who say ‘oh, I gotta hear the heads popping. You gotta lead with your head’. There’s a guy at the old school who taught my son ‘you always lead with your head. That is paramount that you always lead with your head’. [GF4]	Some coaches care more about safety than others Some coaches teach dirty play and fouling on purpose Absolutely, that coach had a dirty team and he had a dirty team because he taught them to be dirty. [GS2] They started just fouling, like intentionally fouling, and there was no control taken from the other coach. At the end of the game, he was kind of like, ‘Oh, sorry about that’. [WS3]
Coaches rely on admins, referees, parents and players to help manage good and bad contact	Clubs and leagues emphasize safety to coaches; but SF says that admin/league/clubs could do more such as tracking penalties The administrators, the coaches, the players –Everybody has to take kind of a shared responsibility with that, and understand that, hey, if we don’t make positive strides in this, then hey, there might not be a game for us to play in the future. [WF8] Admins in GA have authority to step in if safety is compromised Referees are responsible for managing contact during games Stopping play quickly Reminding players about safe play before games Calling penalties or fouls for bad contact like targeting Monitoring bad contact then checking on play and talking with coach Limiting reckless contact Teaching players to change behavior Preventing dangerous tackles Honestly, if we have good referees, a lot of that stops and I’ve seen good and bad referees when I’ve coached, and good ones prevent it very quickly. [GF8]	Admins are responsible for managing contact in the club and train coaches on managing contact Referee is responsible for managing contact during games Stopping play quickly Calling fouls to control contact control game flow The ref controls the flow of the game, so if you let them continue to play dirty, the whole game will be like that. It’ll get more intense and tense after a while. So, if you can slow the game down and call everything you see, they’ll get irritated, but they’ll play a lot cleaner. [GS3] It is up to the ref’s determination on what he sees as overly physical or overly aggressive play compared to this is fine. All refs are gonna call games differently. [GS8] Once it starts, it’s on the referee’s discretion, and their interpretation of the rules which is why our game leads to so much discussion because there isn’t a black and white rule. [GS7] Captains are expected to manage teammates contact Basically, like I try to encourage the captains to keep their teammates level-headed, I guess. So that way they don’t run risk of like hurting someone because their anger. [GS11]
…but	One interviewee noted that parents’ teaching players to avoid physical confrontation can contradict coaches teaching good hits in football Most of these kids are well-adjusted. It is against everything in their DNA and everything they’ve ever been taught to not hit with everything they have. They are taught you don’t hit another person. You don’t push another person down. I am fighting everything they’ve ever been taught to get them to play aggressive football. [GF4] Players need to be aware of what they are doing with their bodies and put into practice what they are taught by coach re: contact It helps a lot, but only as much as the players actually do it because it doesn’t matter if the coach knows the right way to tackle. It’s if he can transition it to the players, and then the players tackle the correct way. [GF6]	One interviewee observed that some parents encourage bad contact because they do not understand soccer; this can contradict coaches’ guidance about contact They tell their kids, ‘That was a good play’. And I tell the kid, ‘No, it wasn’t a good play. I’m calling the whistle. That’s a foul. Don’t do it again’, and they hear their parents kinda egging them on, it’s the parents that aren’t really –I guess, don’t have that soccer background. [GS4] Players need to focus on what they can control in the game rather than what the other team is doing Difficult for coach when ref is not managing contact Controlling player emotion is hard for a referee because you can’t stop the game and tell them to cool down until something happens that warrants game stoppage Like, you can kind of tell when you need to start making calls. And you need to start making more because people are starting to get angry and I think sometimes if I make a lot of calls, like they stop because they’re tired of me making calls. So, I'm like, I’m gonna keep calling everything until they quit. [GS11]
Coaches play the biggest role in managing player contact	Coach responsible for controlling players during game, in the moment Then, one of our players got pushed off a line by a kid on a kickoff return. And then, in pure anger, then just runs out and hits some kid in the side of the head. That was super away from the play. We got flagged. The touchdown didn’t count. And obviously, that’s the kinda situation where A.) We yell at him on the field, and then B.) We show him on film, what he did, how it’s not okay, how it impacts his teammates, how that’s gonna hurt the other player and himself’. [WF5] Removing players from the game We had one of the players would always be placed middle linebacker and he’d always fill his hole. And when he makes his tackle, he’d always have his head down. And I had to take him out of the game and put him on the sideline and explain to him what he’s doing with that. I’d get onto him. If he keeps doing it, I get onto him like my temper will get out there and try to explain to him like dude, I’m really concerned about your safety. If you keep doing that, I can’t play you because I prefer having someone there that will do it right and make sure he’s safe. [GF1] Talking with players about incident immediately I think, for me, a primary job for the coach is to keep it safe playing football. I mean, it’s a violent sport and stuff happens. We’re gonna coach them up. And whether that’s the player making the hit or the player taking the hit. And there’s things the player taking the hit can do and, obviously, if the player making the hit is doing something inappropriate, we’re gonna talk to them about it. [WF4] Evaluating player intent Managing tackling technique	Coach responsible for controlling players during game, in the moment Subbing out/benching players Talking with players about incident immediately Evaluating player intent Encouraging playing to the ref; aggressive play within the rules Removing players from the game when bad contact happens Respecting the game and opponent Modeling good behavior I'm not a paid coach. I don’t get bonuses for wins and losses. I don’t get another job. I don’t move to another club for wins and losses. It’s promoting a sport that I love to kids in the neighborhood. And so, playing it cleanly and the right way is important to me and our club. [WS8] Teaching life skills It’s my job to teach you how to play soccer. But for me I wanna teach them how to be a good person as well. And I think the best thing that I could do is teach them how to become a respectable young man and hopefully take those traits throughout their life. [WS6] Elevating play despite opposition team behavior Managing altercations before they become fights; addressing players and parents after fight Teaching good PC Because my job is to coach them, and coaching is the parameters of life lessons, and learning how to obey rules is a life lesson. [WS9]
The larger community does not appear concerned about bad contact	Coaches do not hear much chatter about physical contact from parents and community Fans are watching for big hits Community supports the football team This community embraces football. So, I don’t think there’s any negative or positive. It’s just like, ‘Hey. We’ve got a great football program’. We’re lucky to have coaches who want to coach, and we’re lucky we’ve got an organization that can afford to put them on the field. And we’re lucky we have a community that supports it. [WF2] Community more concerned about concussions if concerned about anything	Parents are verbal about contact; sometimes encouraging contact and sometimes decrying it Parents that were brought up with soccer and know the game more know that that overly aggressive soccer is not the way soccer’s supposed to be. It’s called ‘the beautiful game’, okay? Well, the beautiful game is not people getting knocked on their ass the whole game. But if you’ve been brought up in a football mentality, deep South, and you see somebody go down hard, you think, ‘Oh, that was a great tackle’. And they think ‘tackle’ means taking somebody out and it doesn’t, and they kind of almost applaud that kind of aggressiveness. [GS4] Community talk about contact tends to be more game-specific or play-specific as opposed to general chatter Parents of club players understand the physical nature of the game Communities accustomed to football culture are tolerant of contact It’s that football mentality that the kids –go from the parents. Maybe the dads played football as a kid. They didn’t play soccer. They didn’t watch soccer, now their kids wanna play soccer, and they take that mentality from the football field to the soccer field. [GS4]
…but	Communities perceive football as the sport with bad contact and corresponding injuries A lot of people associate the more contact with more injuries. Well, I don’t think it’s necessarily true. Injury is the amount of force exceeding tolerances, but I guess some people think that the more contact you have, the more injury. [GF6] Enrolment numbers are down due to parent concerns We can’t even practice against our own team over here. We have that few kids. For me to simulate contact and to do a lot of these things –and I've had this problem before. So, I had a lot more ideas about it but it’s still just really hard to get to that level of physicality. [WF4]	Soccer is perceived as less dangerous than football, in some cases as not tough enough I think trying to change the culture of recklessness and uber toughness in soccer, because soccer, even when I first came in nine years ago, it was you have to prove how tough soccer is because all the people, football is the dominant sport. And if you play soccer, that’s the sport where you put the wimpy kids, who can’t take tackles, that’s it. So, they grow up with this ‘you gotta show how tough the game is’, so they let some of these challenges go which shouldn’t be allowed. [WS4] Soccer parents who are uninformed can misinterpret good contact as bad; parental concern about injury can be high But I think there’s a bit of a miss in understanding that just playing aggressively isn’t playing dangerously. There’s a difference. And I don’t know how often that part is communicated. [WS10] Community concern emerges in the event of injuries
Perceived behavioral control
Coaches are comfortable talking with players about contact	Most coaches report being comfortable talking with players I told them ‘look, this is football. We yell. We have to be loud. But at the end of the day, the only time you’ll ever see me get mad –physically mad on the football field –is if you guys are unsafe. If you’re unsafe your form, if you’re unsafe with your behavior, if you’re unsafe with horsing around, once I see you –if I see you being unsafe, that’s when I get upset and I'll let you know. Other than that, if you drop the ball, if you miss a tackle, we’ll have a conversation about how to be better, but I won’t be upset’. So, yeah. We do talk about it in that way. [WF6]	Most coaches report being comfortable talking with players There’s nothing to hide. We know we’re gonna play soccer… We want you to be more aggressive. And you’re gonna foul someone and you’re gonna get fouled. So, you have to prepare them for that, especially as you go into higher competition. [WS7]
…but	Time and space limit conversations Players’ inattention and potential fear could inhibit Talking before the game may not be the best time Kids may not be paying attention Practices offer more time and better environment for talking about contact Pre-game is time to hype players up Coaches prefer reminder during game, debrief after game, during practice Because I believe in public shaming. And we talked about it and I said I'm not angry with you and this is not –I know that these things happen, but it looks to me like you lowered your shoulder to hurt him. And I appreciate you blocking for your teammate, but we can do –one, you didn’t need to do that block because he was already ten yards ahead so there was no need to do it. And if he’s already ten yards ahead, you need to run down and celebrate with him instead of turning around and looking for somebody to hit. You know and we talk about how if that happened to one of our teammates and one of our teammates got hurt because of it, we would be very angry. [WF9] I'm trying to help them get their head right so that when they get popped by a kid who really actually does wanna hurt them, then they give it back instead of folding up like a lawn chair. [GF4] But our goal is to do that during the week, just making sure that they’re doing practice –doing tackling drills twice a week, and once a week, making sure that we’re doing them right. It’s not really something you preach before a game. [WF5]	Time and space limit conversations Players’ inattention and potential fear could inhibit I think that it’s that worry that we discussed before. I don’t think anyone can perform at their highest level when they’re worried about some external factor, and particularly in this case, when it’s something you can’t control. I think there’s a difference in communication of having a conversation of, ‘Hey, I want us to play safe and take care of ourselves’, than, ‘Hey, look out for this danger’, if that makes sense. [GS1] Talking before the game may not be the best time Kids may not be paying attention Practices offer more time and better environment for talking about contact I don’t think it can be a last-minute reminder. I think you can encourage them to play clean, play safe, and play aggressive, but that baseline, that foundation is set in training and is set in prior games, so right before a game, I think people’s adrenaline is high. Their energy is high. They’re thinking about all these other things. I would rather focus on things I want them to do as opposed to what I want them to not do. [GF5]
Coaches believe talking about contact could make athletes safer	Reminds players about rules, correct technique, and consequences of bad contact All the time, you’ve gotta put that in their head. It helps to remind them. ‘Okay, when this guy’s coming at me, let me make sure I'm making a good tackle or a good block, or whatever it is’. Yeah, even at halftime, reiterating it to them. They’re sponges. You’ve got to keep throwing it at them. Water comes in and runs out just like it does on kids’ brains, heads. [GF9] Because some kids come in with the mentality that this kid’s better than me and I'm gonna have to hurt him. If you talk about it and say ‘hey, this is not okay, don’t do this’, I think it would change that kid. At that age group, you never know. But hearing about it, it could influence them to say ‘hey, we’re just gonna come out here and play football, and if I play hard, maybe I'll be able to beat him besides trying to hurt him’, and stuff like that. Just play your best and then if you play hard, you never know. You might beat him anyway. [GF3] We talk to them and we say, ‘You can’t do that’. And they change, if they don’t change then they don’t play, that’s just how we deal with it. And they usually change based on that if they don’t get to play. [GF8]	Reminds players about rules, correct technique, and consequences of bad contact We spend so much time, I think, trying to encourage our players to be aggressive and physical on the field. I don’t think we really talk about, now that you’re saying it, I’m like, we don’t really give very good specific examples of what would be appropriate, and what would be not appropriate. Because we might actually get the result we want more if we spent more time showing them what was appropriate. [WS11] Safer play occurs because players who play ‘hot’ shift to safer play after coach talk I have one kid who’s kind of a hothead, and he –He needs that talk every time…, so I try to pull him aside. And yeah, I just calm him down, and say, ‘Play the ball’. [WS7]
…but	Not all will play safer as a result of coach talk Negative talk leads to negative action; I prefer to focus on positive talk and encourage appropriate play I’m a firm believer if you tell someone not do it, what are they going to do? They’re probably going to do it. [WF2] Talking about bad contact can cause athletes to overthink and play worse But you need to do it at practice is when you need to talk about safety and prevention because everybody playing the game, they’re not gonna be thinking about how I’m gonna tackle him. They’re just gonna do it, and it’s muscle memory at that point. If they’re out there trying to think of how they’re gonna do it, then they’re probably not gonna be playing very well anyway. [GF6] Some athletes may respond to talk with scared and worried behavior leading to injury I don’t point out the bad things that can happen. I point out, I want to re-emphasize what the good things are. And with that being said, we’ll watch film all week, and say, ‘Hey, you know something, here? Stevie was low blocked’. So, we’ll talk to Stevie all week long, so there should be no reason why we have to bring it back up at the game. The game is all about preparing, and getting your team motivated, and in the right frame of mind, to go out and play a clean, fun game of football. [WF2]	It depends on the player Some players will be more timid as a result of talking about contact Negative talk leads to negative action; I prefer to focus on positive talk and encourage appropriate play Some players are gonna play whatever way they wanna play no matter what you tell them. But you’ll say, ‘I’m lookin’ out for this. I’m lookin’ out for certain that [GS4] One of my philosophies is that you don’t ever say the negative. I’m not perfect on this but if I say to you, don’t do this, what gets dropped is the don’t. So then, what you’re actually telling the kid is do this…. And then in soccer, it’d be play physical. Shoulder to shoulder, legal, keep your arms down, stuff like that. [WS2]

Results

Demographic data for the sample are presented in Table 1. We organized our coding framework by adapting the Theory of Planned Behavior (TPB) (Ajzen, 1991) to identify factors influencing coach communication about ‘good’ and ‘bad’ contact during sport (Figure 1). Of note, we chose the terms ‘good’ and ‘bad’ as we used these in the interviews about contact and they were understood by all stakeholders. Using the framing of TPB, we theorized that:

Figure 1. Conceptual model of factors impacting coach communication about good and bad contact with youth athletes, framed using the Theory of Planned Behavior.

Table 1. Demographics of coaches, referees and administrators participating in qualitative interview study regarding coach communication about physical contact in youth sports 2019–2020.

	Western Washington (n = 27)	Southern Georgia (n = 23)
	n(%) or m (SD)	n(%) or m (SD)
Position
Administrator	3 (11.1)	3 (13.0)
Coach	24 (89.9)	12 (52.2)
Referee	0	8 (34.8)
Sport
Football	9 (33.3)	9 (39.1)
Soccer	18 (66.7)	14 (60.9)
Gender
Female	3 (11.1)	4 (17.4)
Male	24 (88.9)	19 (82.6)
Hispanic or of Mexican or Latin American descent
Yes	1 (3.7)	4 (17.4)
No	25 (92.6)	19 (82.6)
Unsure	1 (3.7)	0 (0)
Race
Caucasian or White	23 (85.2)	20 (87.0)
African American or Black	2 (7.4)	2 (8.7)
Other	2 (7.4)	0 (0)
Age (categorical)
15–24 years	1 (3.7)	8 (34.8)
25–34 years	4 (14.8)	6 (26.1)
35–44 years	9 (33.3)	6 (26.1)
45+ years	13 (48.2)	3 (13.0)
Age	41.70 (10.0)	32.48 (12.6)
Highest level of education
Some college but no degree	2 (7.4)	7 (30.4)
Associate or Bachelor’s degree	21 (77.8)	11 (47.8)
Master’s degree or higher	4 (14.8)	5 (21.74)

• Knowledge/experience about contact influences Attitudes/beliefs about contact

• Attitudes/beliefs about contact, Norms/values about contact and Perceived behavioral control about contact all influence whether and how coaches communicate about good and bad contact with youth athletes.

We report our findings by domain/subdomain/quote (Table 2), stratified by sport (football and soccer). For some domains, there were more similarities across the whole sample than differences between sports, and we noted where that occurred. Additionally, where there was a difference by geography, we highlighted the difference; generally there were more similarities than differences between states. Where differences seemed significant, we denoted that in the table with initials representing geography (G or W for Georgia or Washington) and sport (F or S for football or soccer). Our focus was on coaches as the primary conduit to players, but we included findings related to referees where relevant as they were components in the larger context of game-time contact.

Themes

Knowledge/experience

Knowing the difference between good and bad contact

Coaches easily described both good and bad contact for their individual sports, but particularly for football. Good contact in football was both the actions (proper tackling and blocking including keeping the head out of the play) and also the underlying ethic of playing in a ‘safe sportsmanlike way’. (GF1) Football coaches had an image of ‘perfect’ tackling: ‘Leading with your shoulder and not your head and having a target zone between the hip and the shoulder…a good square contact, wrap and drive’. (WF1) Soccer coaches talked about the importance of ‘trying to win the ball not…hurt the player’ (WS1) and ‘playing by the rules’, while acknowledging, ‘it’s a physical game…you have to be willing to be physical’. (WS2) Football stakeholders described bad contact as blindsiding, helmet-to-helmet plays and hitting after the play, noting: ‘There’s more involved with penalties than just you’re trying to get an advantage over the other team. It’s also the safety of the player’. (WF2) In soccer they discussed kicking, tripping, and using arms rather than shoulders. In both sports, interviewees pinpointed fighting as bad contact and talked about how intention divided good contact from bad. Intent to injure or hurt the opponent resulted in ‘bad’ contact, which could be driven by anger or recklessness: ‘There’s that line where some kids are out there, and they got mad or really want to hurt somebody, so that could be part of the bad contact’. (GF2)

Attitudes/beliefs

Bad contact is more likely to cause injury

Across the sample, interviewees talked about bad contact causing injuries to both initiating and receiving players. In football these events included ‘bad’ tackling and blocking, ‘…especially using the crown of their helmet’. (WF3) In soccer, players had been injured when they slide tackled, played recklessly and used headers without proper form. Interviewees talked about ‘cheap shots’ performed to cause injuries; in football this included hitting defenseless players and hitting after the whistle, and in soccer aggressive fouls and retaliatory moves. Soccer respondents talked about the importance of referees setting expectations and managing games to control contact and minimize risk of injuries. This was noted as especially important when aggression was escalating: ‘when anger comes into play, then I think that increases that testosterone and the power behind the physical contact, and that’s when I personally see injury occur’. (GS1)

Bad contact is often not intentional

Bad contact happened even with the best of intentions and was often attributable to the same issues across football and soccer: lack of body control/technique/coordination and poor execution within the rules such as playing after the whistle, playing the player rather than ball and poor timing during tackles. Stakeholders from both sports cited size differential as a possible cause of bad contact, especially for young players, and declared that players needed to learn to anticipate contact so they could physically prepare for the interaction: ‘The thing is how to keep your head, how to swivel’. (WF2). Football coaches described football as ‘a violent contact sport’ and soccer coaches said players ‘use aggression’ so there would always be a risk, but danger could be tempered by training, technique and good intentions. In both sports, stakeholders felt younger players lacked coordination, spatial awareness and self-control, all of which could contribute to bad contact and result in injuries even with no intent to harm: ‘Someone’s trying to win the ball and they just misjudge an angle, or they go down earlier than they expect, or whatever, and it’s going to result in a dangerous play, but wasn’t intended’. (WS3)

Norms/values

Everyone is responsible for managing player contact

Management of contact was seen as a shared responsibility between coaches, opposing coaches, administrators, referees, parents and players: ‘Obviously, we’re gonna talk in practice about it, but if something’s going on in the game, there’s a limit to what we can do–that one is on the officials. And it’s also on the other coach’. (WF4) Respondents saw themselves and other coaches as responsible for teaching good technique and following up with corrections for bad contact which could include removal of players who were too emotional to manage themselves. They talked about the challenge of focusing on good contact (in keeping with larger sports philosophies of focusing on the positive) balanced against correcting bad contact. When probed to reflect on their experience with opposing coaches, they described a spectrum of concern from some who were focused on safety and good conduct to others who encouraged illegal play and fouling: ‘Absolutely, that coach had a dirty team and he had a dirty team because he taught them to be dirty’. (GS2) Referees were seen as having a unique and critical role for managing contact in games through pre-game reminders and controlling game physicality via calling penalties/fouls, stopping play quickly and limiting reckless contact: ‘The ref controls the flow of the game, so if you let them continue to play dirty, the whole game will be like that’. (GS3) Soccer respondents explained how referees, in turn, rely on team captains to manage their teammates. Parents, too, were mentioned as part of this collaborative cluster, but the few comments about parents indicated they sometimes contradicted the coach by either overprotecting players (football) or encouraging inappropriate play (soccer): ‘They tell their kids, ‘That was a good play’. And I tell the kid, ‘No, it wasn’t a good play. I’m calling the whistle. That’s a foul. Don’t do it again’.’ (GS4) Players, on the other hand, were seen as critical to intentionally controlling their own bodies, practicing what coaches teach regarding contact, and focusing on their own actions in games rather than on the opposition.

Coaches play the biggest role in managing player contact

Coaches identified themselves as ultimately responsible for managing contact across both football and soccer. While many agreed that talking with players about contact was important, coaches identified practices, post-game debriefs and brief game-time reminders as preferable to pre-game talks that might conflict with pre-game hype sessions: ‘We show him on film what he did, how it’s not okay, how it impacts his teammates, how that’s gonna hurt the other player and himself’. (WF5) At game time, football coaches talked about encouraging good tackling technique and playing in a sportsmanlike manner, while soccer coaches talked about playing to the referee, aggressive play within the rules, and respecting the game and opponent. Coaches felt responsible for modeling good behavior and teaching life skills. Soccer coaches focused more on how to support good contact, while football coaches talked more about managing bad contact. Coaches had the power to address bad contact when it happened and they used this power via talking with players, evaluating intent and at times removing them from play.

The larger community does not appear concerned about bad contact

Respondents spoke mostly about parents when reporting on community concerns. They described a complex set of opinions expressed by the community that varied by sport. The football community was seen as supportive of football teams and engaged by the physicality of the sport: ‘This community embraces football…it’s just like ‘Hey, we’ve got a great football program’.’ (WF2) However, football enrollment had been declining in some locations due to injury risk, and coaches were openly concerned about the difficulty fielding teams: ‘We can’t even practice against our own team over here, we have that few kids’. (WF4) For soccer, discussions about contact seemed directly connected to games and specific plays. Interviewees from both sports commented on a general community perception that football has more bad contact and corresponding injuries than soccer, with one participant commenting that soccer is seen as being for ‘wimpy kids who can’t take tackles’. (WS4)

Perceived efficacy and behavioral control

Coaches are comfortable talking with players about contact and believe talking about contact could make athletes safer, but they also worry about causing fear

Coaches in both sports reported feeling confident and comfortable talking about contact with their players, but also noted there were time limits (especially right before games) and players at this age can be inhibited by lack of attention. Some coaches were concerned about finding the best way to talk with their players about the reality of sport injuries and game penalties without causing them to ‘play scared’, which could also result in injury: ‘I don’t think anyone can perform at their highest level when they’re worried about some external factor’. (GS1) The default approach seemed to be to encourage positive aggressive and physical play, and only a few talked with players about consequences of bad contact (both pre-game and in the moment): ‘I’m all about the positive things, the positive side of things…I’m a firm believer if you tell someone not to do it, what are they going to do? They’re probably going to do it’. (WF2) Practices were seen as the preferred opportunity to talk about contact as this provided more time and space for discussion: ‘I don’t think it can be a last minute reminder. I think you can encourage them to play clean, play safe and play aggressive, but that baseline, that foundation is set in training’. (GS5) Respondents reported that talking about contact is an important part of being a good coach and had the potential to make athletes safer: ‘Some kids come in with the mentality that this kid’s better than me and I’m gonna have to hurt him. If you talk about it and say ‘Hey, this is not okay, don’t do this’, I think it would change that kid’. (GF3) However, not all coaches could see a direct correlation between talking about contact and safe, injury-free play: ‘Some players are gonna play whatever way they wanna play no matter what you tell them’. (GS4) Youth football and soccer athletes play very physical games, and coaches felt the need to strike a balance between instruction about good/bad contact with encouraging, positive, enthusiastic coaching to produce confident, aggressive players: ‘I’m trying to help them get their head right so that when they get popped by a kid who really actually does wanna hurt them, then they give it back instead of folding up like a lawn chair’. (GF4)

Discussion

We conducted a qualitative interview study (framed using the TPB) (Ajzen, 1991) to elucidate factors influencing coach communication with youth athletes about contact and injury risk in sport, with a goal of informing interventions utilizing coach communication about good and bad contact as a means to injury prevention. We assessed how coaches perceived and talked about contact with their athletes to determine: 1) coach perception of appropriate and acceptable content for messaging regarding contact and 2) barriers and facilitators to coaches talking about good and bad contact with their athletes. Football and soccer coaches could clearly describe good and bad contact (Knowledge/experience) and they recognized the connection between bad contact and injury (Attitudes/beliefs). They also believed it was their role to teach youth athletes about contact and injury risk (Norms/values), while emphasizing that all adult stakeholders (referees, parents, administrators) had a role to play. They felt comfortable having these discussions (Self-efficacy) and most believed that discussions with athletes about contact could decrease injury (Response efficacy), but they also raised concerns that talking about contact would take time, might not be effective and might cause a fear of injury. Stakeholders from both football and soccer felt it was essential to correct bad contact when it occurred. However, when talking before a game, they preferred to focus on the positive (i.e. ‘Keep your head up’ rather than ‘Don’t put your head down’). Coaches rarely discussed institutional guidance about addressing contact in the coach role.

Asking football coaches to talk to athletes about contact would be relatively straightforward given stakeholder recognition about the need to prevent concussive injury in football, and an acceptance that certain types of contact (such as tackling with head down) are associated with greater likelihood of concussion (Obana et al., 2021). In addition, the effective implementation of programs such as Heads Up Football® (Matsuo et al., 2018; Shanley et al., 2021; Tokish et al., 2017) and the frequent use of terms like ‘hawk tackling’ and ‘rugby style tackling’ suggest the cultural acceptance of teaching good and bad contact as a means for reducing injury risk in football. Efforts to reduce concussive injury in football have been more urgent in recent years with reports of declining enrollment (McGlynn et al., 2020). Some organizations have even chosen to institute injury prevention programs such as Heads Up Football® with a goal of improving the image of youth football for concerned parents.

Soccer, on the other hand, has a more challenging culture in which to promote discussions about contact and injury as key stakeholders are conflicted about whether concussion is a significant issue in the sport (Kim & Connaughton, 2021), even with studies showing a relatively high incidence of concussion in soccer (Bretzin et al., 2021). In addition, research on the mechanism of soccer concussions is still in its infancy, and other than heading, which is known to be associated with greater likelihood of colliding with another player and thus sustaining an injury (Comstock et al., 2015), it is not clear which types of soccer contact place an athlete at greater risk for concussion. Interestingly, heading was not a frequent theme in these interviews, perhaps because avoiding a collision during a heading attempt is more complex and would require greater training (Quintero et al., 2020). The soccer stakeholders in the sample mentioned concerns about ‘aggressive play’ and ‘not tackling from behind’ which are thought to be potentially more injurious, but evidence linking these behaviors to injury is scant. Even soccer rules are vague on this concept, suggesting that ‘playing in a dangerous manner’ could be grounds for a foul, but not defining what is meant by ‘a dangerous manner’. Injury prevention programs in soccer have primarily focused on strength and conditioning and have not addressed aggressivity or ‘bad’ contact. Recent surveys of parents suggest growing concern about concussion in youth soccer which the sport will need to address in some fashion (Kim & Connaughton, 2021). While it is possible that discussing good and bad contact in soccer could be an effective means towards injury prevention, more work will need to be done to understand how to implement such an approach.

It is notable that coaches were hesitant to have discussions about contact that ‘went negative’, expressing concern that this might spark fear of injury in their players and cause them to back off in terms of aggressivity, often a necessary part of success in sport. Interestingly, a focus on positive instruction is recommended for other types of behavior change, as instruction that focuses on the negative (e.g. ‘Don’t bend your elbow’) tends to increase a behavior compared to the same command framed positively (e.g. ‘Keep your arm straight’) (Evans & Tuttle, 2015). In other words, in the context of football one could talk about ‘keeping your head up’ and for soccer ‘using your shoulder or hips to box them out’. Framing communication positively and focusing on the desired behavior rather than the undesired behavior is a more effective approach, and should be considered for future interventions utilizing communication about contact.

Perhaps one of the deeper questions this research raises is the issue of balancing aggression and injury risk in sport, an underlying issue for all sports. Athletes at the highest levels of competition always risk the possibility of causing injury to themselves or others. They do not enter into competitions with a goal of hurting their opponent; their goal is to win. As public health researchers, our job is to provide coaches, athletes and sporting organizations/national governing bodies (NGBs) information about strategies to mitigate injury risk that allow them to continue to grow the sport they love. Football has changed many times over the years in an effort to make the game safer, including outlawing the flying wedge (McQuilkin & Smith, 1993), developing the forward pass (Watterson, 1981) and prohibiting spearing (Heck, 1992). Utilizing approaches with preventive messaging about contact (such as having the shoulder be the first point of contact rather than the head) has the potential to make football safer, particularly for youth. However, in order for this type of approach to be successful, the messaging needs to be 1) mandated by the league and 2) implemented in a way that fits with the culture of the sport.

Limitations

The goal of this study was to identify factors influencing coach communication with youth football and soccer players about contact and injury risk, and we interviewed 50 individuals from two states (Washington and Georgia) as a strategy towards developing a more generalizable sample. However, despite our careful sampling, the individuals we interviewed were predominately male (86%) and white (86%), which unfortunately represented the individuals who worked in these spaces, even in Georgia which had greater racial diversity. We acknowledge that females and people of color might have different approaches to thinking about good and bad contact and further work will need to be carried out to ensure their voices are included. We also acknowledge that the inferences we make in this paper are still only theoretic, and quantitative work is needed to explore the strength of these factors and the pathways whereby they might influence stakeholder communication in greater detail.

Conclusions

Most coaches in youth football (i.e. American football) and soccer know that certain types of contact like targeting another player can be dangerous, and they teach their athletes to engage in ‘good’ contact to minimize risk of injury. Youth coaches appear to employ purposeful communication strategies regarding contact, focusing on positive instructions like: ‘keep your head up’ and ‘play the ball not the player’. However, while referees have a clear mandate regarding player safety, coaches are not usually told by their organizations that managing contact is part of their role. Future sport injury prevention programs developed by academicians, sporting organizations or NGBs (National Governing Bodies) might consider a greater role for coach communication about approaches to engaging in contact that minimize injury risk.

Author contributions

Sara Chrisman applied for and received grant funding to carry out the study (MPI), developed and refined the structured interview, oversaw data collection and analysis including interpretation of results, and generated the final manuscript.

Emily Kroshus worked alongside Dr. Chrisman to apply for and received grant funding (MPI) to carry out the study, participated in the generation of the structured interview and data analysis, and reviewed and edited the final manuscript.

Rachel Hays supported development of the structured interview, coordinated all data collection and participated in analysis and interpretation, supporting several research coordinators to carry out data coding and synthesis, and reviewed and edited the final manuscript.

Erin Kinney helped refine the structured interview, conducted interviews of participants in Washington, engaged in data coding and synthesis, and reviewed and edited the final manuscript.

Kiana Hafferty helped refine the structured interview, conducted interviews of participants in Washington, engaged in data coding and synthesis, and reviewed and edited the final manuscript.

Beth Bollinger supported data analysis and interpretation, and reviewed and edited the final manuscript.

Tamerah Hunt oversaw data collection in Georgia including completing some of the interviews, participated in data analysis and interpretation, and reviewed and edited the final manuscript.

Nicole Walden conducted interviews of participants in Georgia, engaged in data coding and synthesis, and reviewed and edited the final manuscript.

Stephanie Fletcher conducted interviews of participants in Georgia, engaged in data coding and synthesis, and reviewed and edited the final manuscript.

George Chiampas assisted with development of the grant for funding, provided support and engagement for data collection, helped develop the structured interview, participated in data interpretation, and reviewed and edited the final manuscript.

Dane Ramshaw assisted with development of the grant for funding, provided educational resources for the study to assist with data collection, developed conceptual model materials, and reviewed and edited the final manuscript.

Kirsten Senturia oversaw all qualitative data collection including development of the structured interview, training and supervision of research coordinators to complete data coding and synthesis, and engagement with final data interpretation, including reviewing and editing the final manuscript.

Ann Glang supported development of the grant for funding, worked with MPIs Kroshus and Chrisman to engage coaches and other key stakeholders, participated in data analysis and interpretation and reviewed and edited the final manuscript.

Acknowledgements

We would like to thank the youth coaches, referees and administrators in Washington and Georgia without whom this study would not have been possible.

Disclosure statement

Dr. Chiampas is chief medical officer for U.S. Soccer. The authors otherwise have no conflicts of interest to declare.

Data availability statement

The authors have agreed to make data and materials supporting the results or analyses presented in this paper available upon reasonable request.

Additional information

Funding

This work was made possible by a grant from the Centers for Disease Control and Prevention, U01CE002880

Notes on contributors

Sara P. D. Chrisman

Drs. Chrisman and Kroshus are researchers at Seattle Children’s Research Institute and have worked together for several years to develop a novel injury prevention program (Huddles), in partnership with US Soccer. Dr. Chrisman is a pediatrician, epidemiologist and physician scientist and Dr. Kroshus is a social scientist and implementation specialist.

Emily Kroshus

Drs. Chrisman and Kroshus are researchers at Seattle Children’s Research Institute and have worked together for several years to develop a novel injury prevention program (Huddles), in partnership with US Soccer. Dr. Chrisman is a pediatrician, epidemiologist and physician scientist and Dr. Kroshus is a social scientist and implementation specialist.