Protocol design for large-scale cross-sectional studies of sexual abuse and associated factors in individual sports: feasibility study in Swedish athletics.

Author:Timpka, Toomas


The International Olympic Committee (IOC) encourages international sports federations and national sports governing bodies to maintain safety with regard to sexual harassment and abuse for all groups of athletes (IOC, 2008). The risk for sexual abuse is unknown in most sports settings due to the challenge of conducting epidemiological studies on this subject which is often hidden by athletes. Correspondingly, the main motivation for epidemiological studies of sexual abuse in sports is the need to tailor preventive interventions to subgroups of athletes, taking into regard, e.g. age group, sex, and characteristics of the sexual abuse itself (Leventhal, 1998). Surveillance and design of interventions require repeated collection of individual-level data. Athletics (track and field) is a popular sport worldwide with international championships organized for athletes from 17 years of age. In 2013, the International Association of Athletics 54 Federation (IAAF) represented 212 national athletic federations ( Due to the wide geographical distribution of participants, the monitoring of safety in an individual sport such as athletics requires elaborated infrastructural means, such as the use of Internet-based information technology (Jacobsson et al., 2010).

The design of surveys about sexual abuse is challenging regardless of the targeted population, and a study among athletic athletes constitutes no exception. It is in the interest of sports organizations accepting a social responsibility for their athletes to be able to offer preventive measures against sexual abuse, while simultaneously survey designs should not breach confidentiality. We set out to design a study protocol with documented design decisions for cross-sectional epidemiological studies of sexual abuse in athletics and to evaluate its feasibility. The study protocol is to be used to investigate lifetime prevalence and to identify factors that can be used to inform primary prevention and interventions for support of sexual abuse victims. The purpose is to provide a methodological platform for easily implementable and reliable epidemiological studies of sexual abuse in sports settings. Ethical aspects has restricted the possibility of conducting prospective population-based studies of maltreatment among young people (Kendall-Tackett and Becker-Blease, 2004), and consequently retrospective studies are a recommended approach (Butchart et al., 2006; Sethi et al., 2013)--despite the risk of recall bias inherent in this survey method (Hardt and Rutter, 2004).

Prevalence and correlates of sexual abuse: There are relatively few epidemiological studies reporting on the prevalence of sexual abuse victims in sport. A Norwegian study where elite female athletes were compared with a sample of age-matched controls showed no overall differences between the groups, but the prevalence of sexual harassment and abuse in athletes increased with age. The female athletes had experienced abuse from both men and women, and the prevalence rate of athletes' experiences of sexual harassment and abuse from male authority figures in sport was greater than what the controls had experienced in a workplace or educational setting (Fasting et al., 2003). A large-scale survey study from Australia reported that 13% of female and 6% of male participants in organized competitive sport had experienced sexual abuse in the sport environment (Brackenridge and Fasting, 2008). Regarding specific risk factors, an investigation of student-athletes and coaches on perceptions of interpersonal coach-athlete relations found that 2% of the athletes had experienced sexual abuse in sport, and 3% of the coaches admitted to having been intimately involved with an athlete under the age of 18 years (Brackeridge and Kirby, 1997). Apart from coach-related factors, the athletic maturation of the athlete (Tofetgaard, 2001), sport type (Fasting et al., 2004), and the subculture of sport (Bringer et al., 2001) have been discussed as areas mediating the risk for sexual abuse.

In comprehensive meta-analysis of 217 publications covering about 10 million children and adolescents in the general population, 127/1000 of participants reported to have been exposed to sexual abuse (Stoltenborgh et al., 2011). Variations in prevalence rates between different studies can be explained by differences in definition of sexual abuse, measurement, samples, and reporting methods (Fergusson and Mullen, 1999, Peters et al., 1986). The variations can also result from real differences in different cultures, either within multicultural populations (Kenny and McEachern, 2000) or between different countries. Fergusson et al. (1997) and Halperin et al. (1996) separate between three types of sexual abuse: abuse without contact, abuse with contact (no penetration), and abuse with contact and penetration. A study using this definition of 18-year-olds in Norway, Lithuania, Estonia, Sweden, and Poland reports that the prevalence rate of penetrating abuse was rather evenly spread among females from all five countries (Mossige et al., 2007). Regarding associations between sexual abuse and sociodemographic variables, there is in the literature substantial agreement concerning family structure in that not living with both biological parents places a child at higher risk for sexual abuse (Fergusson and Mullen, 1999; Holmes and Slap, 1998). Concerning ethnicity and sexual abuse, Finkelhor and Baron (1986) observed that studies have not found Black-White differences, but hints of possible differences for other ethnic group. Rickert et al. (2004) and Fergusson et al. (1997) found no differences between ethnic groups. Edgardh and Ormstad (2000) found no differences concerning immigrant background in a Swedish sample. Also, adolescents with a history of sexual abuse have been shown to be younger at first consensual intercourse than non-abused adolescents (Edgardh and Ormstad, 2000; Fergusson et al., 1997).


An argument-based method for investigation of complex design problems (Rittel and Webber, 1973) was employed to structure the collection and analysis of the data used for the protocol design. Examination of requirements on study of sexual abuse in athletics was followed by iterated drafting of protocol specifications and pilot tests. The feasibility of the resulting protocol was evaluated in association to implementation in a national-level study among elite athletics athletes in Sweden.

Requirements data collection

A nominal group process was used for the requirements analysis. Two expert panels examined requirements on the data to be collected by the study protocol and the study implementation process, respectively (Figure 1A). Individual expert's reviews of working requirements document were followed by telephone discussions. Requirements on the data to be collected were defined by a panel consisting of scientists and practitioners (n = 8) with backgrounds in sports medicine and epidemiology, social medicine, child and adolescent psychiatry, biostatistics, and medical psychology. The panel examining requirements on implementation of the study in practice consisted of experts with backgrounds in athletics coaching, social medicine, biostatistics, health informatics, and cognitive science. All experts provided a first round of comments to the study coordinator, who assembled these into a protocol requirements document. When subsequent turns did not return with significant changes in the document, the requirements were considered finalized.

Design specification

The outcomes of the requirements analysis processes were transferred to a study protocol specification procedure. Representatives from the two panels (n = 7) were merged into one panel for specification of the protocol design (Figure 1B). The task communicated to the group was to formulate a preliminary study protocol using the requirements, their personal expertise, and the published literature. The experts first provided their individual design suggestions, which were collected by a design process coordinator. Formulation of these suggestions was performed independently by each expert. A working study design document was repeatedly circulated to the entire expert group and a consensus document was progressively established. The experiences from this process were documented as design issues and their solutions. In the third and final step, the document was approved as the preliminary study design protocol to be used in formative evaluations.

Formative evaluations

Two formative evaluations were performed of the preliminary protocol. In the first evaluation, a cognitive walkthrough review was performed of the definition of sexual abuse (used to collect data for the dependent variable) in the preliminary protocol. Six athletes and coaches individually reviewed the corresponding section of the protocol. The reviewers were instructed to report if they noted any ambiguities or vague formulations, lack of suitable alternatives or risk of misinterpretation and what the consequences of these observations would be. The reviewers' reports were analysed and the preliminary protocol revised.

The second formative evaluation of the prototype survey protocol was performed in a pilot study that was carried out among adult and youth athletes (n = 9). The participants were asked to fill in a survey based on the prototype protocol and thereafter complete a questionnaire. The questionnaire data were used to revise the protocol into its final version. The protocol design was specified in terms of the main self-report questions and the basic format for statistical analyses.

Feasibility evaluation

The feasibility of the protocol was examined by implementation in a study involving all youth and adult elite athletes listed by Swedish Athletics. The web-based system for data collection is based on a commercial product for collection of survey data over the world wide...

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