Evaluation of a stress prevention program for young high-performance athletes

Author’s Accepted Manuscript Evaluation of a stress prevention program for young high-performance athletes P. Dallmann, C. Bach, H. Zipser, P.A. Thomann, S.C. Herpertz www.elsevier.com/locate/mhp

PII: DOI: Reference:

S2212-6570(15)30021-0 http://dx.doi.org/10.1016/j.mhp.2016.04.001 MHP56

To appear in: Mental Health & Prevention Received date: 13 November 2015 Revised date: 27 April 2016 Accepted date: 27 April 2016 Cite this article as: P. Dallmann, C. Bach, H. Zipser, P.A. Thomann and S.C. Herpertz, Evaluation of a stress prevention program for young high-performance a t h l e t e s , Mental Health & Prevention, http://dx.doi.org/10.1016/j.mhp.2016.04.001 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Evaluation of a stress prevention program for young high-performance athletes Dallmann, P. 1, Bach, C. 1, Zipser, H. 1, Thomann, P. A. 1,Herpertz, S. C. 1 1

Department of General Psychiatry, Center for Psychosocial Medicine, Heidelberg University,

Corresponding author Petra Dallmann [email protected] Further authors: Prof. Dr. Sabine C. Herpertz [email protected] MSc.-Psych. M.A. Claudia Bach [email protected] Hellen Zipser [email protected] Prof. Dr. Philipp A. Thomann [email protected]

Heidelberg University Hospital Center for Psychosocial Medicine General Psychiatry Voßstr. 4 69115 Heidelberg Germany Funded by the Ministry of Science, Research and the Arts in Baden-Württemberg. Approved by the Ethics Committee of the Medical Faculty of the University of Heidelberg (No. S-017/2014). 1

Abstract Objective: The present study evaluated the effectiveness and acceptance of a stress prevention program for young elite athletes in education. Method: In a non-randomized controlled trial 28 elite athletes (swimming, basketball, boxing, weight lifting) participated in a stress prevention training. The control group, consisting of 28 elite athletes (swimming, basketball, soccer, boxing, weight lifting, wrestling, triathlon), did not receive a training. Mean age was 17.50 years in the experimental group and 16.36 years in the control group. 75.0%, respectively 67.9% were female. The main outcome measures were perceived stress, self-efficacy and knowledge about stress and stress prevention before and 4 weeks after the program. Additionally, program satisfaction was analyzed in the experimental group. Results: Participants of the experimental group showed significant improvements in self-efficacy and knowledge in the analysis with the paired t-test, ANOVA results only revealed a trend for a significant effect on knowledge. No significant effects were found in the control group. Participants rated our prevention program as beneficial and recommendable. Conclusion: The training program increased the knowledge about stress and stress prevention and had a positive effect on self-efficacy.

Keywords: stress, stress prevention, stress management, athletes, self-efficacy

2

Introduction

For a long time, mental disorders were a topic rarely talked about in the world of high performance sports despite athletes having to endure high physical and mental challenges often already at a young age. Following several prominent elite athletes’ and coaches’ public reports about burnout and depression worldwide, both experts and the general public have become more aware of this problem.

Moreover,

athletes themselves have become more mindful of mental problems though data suggests that the prevalence of depression does not differ largely from the general population (Nixdorf et al. 2013, Yang et al. 2007). In a study from Breuer and Hallmann (2013) 11.4% of the questioned elite athletes reported to be suffering from burn-out while 9.3% stated to have depressive disorders. The relationship between stress and depression is generally accepted (Kessler 1997). Extant literature suggests that this correlation also exists between high performance athletes’ depressive symptoms and chronic stress (Nixdorf et al. 2013). Kleinert et al. (2010) detected stress-associated complaints among elite athletes; 46% felt little regeneration after sleep, 16% felt insufficiently recuperated and 13% were unsatisfied with their stress management. Also, insufficient recovery is correlated with depressive symptoms (Nixdorf et al. 2013) and might increase overtraining and risk of injury (Andersen & Williams 1999). Furthermore, overtraining syndrome itself has been connected to depressive disorders (Armstrong & VanHeest 2002). In most competitive sports, the training workload is high during adolescence. On average, elite German athletes train 18 hours per week and spend another 14 hours with sport related activities, such as travel time, competitions, and physiotherapy (Breuer & Wicker 2010). Furthermore, absenteeism from school or university due to training camps or competitions has to be considered. In consequence, elite athletes not only have to deal with high workloads in training but also have to take care of their education at the same time. Especially, before graduation students’ have to cope with high pressure levels. Correspondingly, athletes report that school is a key stressor and that they found it difficult to combine sport and schooling (Gustafsson

3

et al. 2008). In light of training and educational demands as well as the high pressure to compete, conflicts within the team or with the coach, possible injury and being in the public eye, it is not surprising that elite athletes report a higher stress level than the corresponding age group in the population (Richartz et al. 2010). Nixdorf et al. (2013) showed a correlation between coping strategies and depressive symptoms of elite athletes, therefore, suggesting that the acquisition of such strategies might prevent them. Correspondingly, in a review, Rumbold et al. (2012) stated that stress management programs for elite athletes, especially multimodal interventions, have a positive effect on various stress components. However, all interventions analyzed in the review only measured the athletes’ competitive stress experience. The authors criticized that up to now organizational stress and personal stress have been neglected. Perna et al. (2003) developed a cognitive behavioral stress management with seven 35-40 minute sessions. Besides explaining stress, somatic and cognitive strategies were implemented for stress reduction and emotional expression was also encouraged. The program’s main aim was to reduce athletes’ days of absenteeism due to injury or illness. Results showed a significant reduction of absenteeism due to illness or injury and less negative affect. To date, stress prevention programs for elite athletes are rare. Furthermore, many exiting programs focus on the improvement of athletic performance or the prevention of injury and not on the prevention of stress or mental illness. The purpose of this study was to develop an intervention program which reduces stress. The program consists of six sessions, each lasting 30 minutes, which took place once a week for the experimental group. The program content comprised symptoms, development, and consequences of stress, relaxation techniques, mindfulness, cognitive restructuring, balance, social contacts, overtraining, and extrinsic and intrinsic motivation. The control group did not receive any intervention. The study was evaluated in terms of perceived chronic stress, self-efficacy, knowledge about stress and satisfaction with the program. We hypothesized that the experimental group would feel less stressed, show more self-efficacy, and have greater knowledge about stress after the intervention in comparison to the control group.

4

Methods Procedure The project „Stress prevention training for young athletes“ is part of the center of excellence for the prevention of psychological and psychosomatic disorders in the working and educational world, which was funded by the Ministry of Science, Research and the Arts in Baden-Württemberg. To note, the study design was not a randomized controlled design. Analyzed data were obtained between April and August 2014. Participants were recruited by contacting coaches and Olympic Training Centers in Heidelberg, Munich, and Freiburg. Inclusion criteria were (1) the attendance of school or university and (2) the competitive performance of sport on a top national level with training taking place on at least 5 out of 7 days and (3) an age between 15 to 25 years. After recruiting elite athletes for the experimental group, we looked for matching elite athletes (age, gender, type of sport, competitive performance level, training load) for the control group. All participants were investigated at baseline (T0) and again approximately 10-12 weeks later (T1) and data were obtained via self-report questionnaires as detailed below. For the experimental group, the stress prevention program took place right after T0 for the duration of 6 weeks. There was one session per week which lasted 30 minutes. T1 data were obtained at a 4 week follow-up after the end of the program. The group size ranged between 9 to 13 students. The program took place at the athletes’ training site or boarding school. The controls received no intervention. The two intervention trainers were employees of the Department of General Psychiatry at the University Hospital in Heidelberg with a background in highperformance sport. Most groups were chaired by the same trainer (a female, 35 year–old, resident physician) who also trained the second trainer, a 23 year-old female medical student. The study was fully explained to all participants. Informed consent was obtained from each participant and the protection of data privacy was guaranteed. All measurements were conducted in accordance with the Declaration of Helsinki. If they were under the age of 18, their parents were also informed and provided 5

written informed consent. The study was approved by the Ethics Committee of the Medical Faculty of the University of Heidelberg (No. S-017/2014).

Stress prevention program We developed a program, which aimed to meet the unique demands of young elite athletes performing on a top national level while attending schooling or university at the same time. We conducted a literature search for existing stress management programs and sport specific risk factors for burn-out. We interviewed the director, coaches, sport psychologists and the career advisor of the local Olympic Training Center in order to gain a comprehensive picture of elite athletes’ stress factors. The program’s six sessions of 30 minutes were structured as follows: during the first two sessions, the development, symptoms, and consequences of acute and chronic stress were explained. Thereafter, stress management and prevention sessions included cognitive strategies, balance, mindfulness, relaxation techniques and the importance of social contacts. Over-training syndrome and extrinsic and intrinsic motivation in high performance sports and their relationship to burn-out (Table 1) were the covered sport specific topics. Each session was started with a short summary of the last session.

[Table 1 near here]

Sample The valid sample was N = 56; N = 28 of them were included in the stress prevention training and N = 28 in the control group. Participants who did not complete the questionnaires at T0, T1 or who took part in less than four stress prevention sessions were excluded from statistical analyses. The sample characteristics are provided in Table 2. For the whole sample, the age range was 15 - 25 years with a mean value of 16.93 years (SD = 2.33). A total of 71.4% of the participants were female. On average, participants of the experimental group were 17.50 (SD = 2.80)

6

years and 75.0% were female. Participants of the control group were 16.36 (SD = 1.59) years of age and 67.9% were female. The experimental group consisted of swimmers (n = 15), basketball players (n = 9) and athletes attending a sports boarding school (n = 4), three of them active in the sport of boxing (n = 3) and one in weight lifting (n = 1). The control group consisted of swimmers (n = 12), basketball players (n = 6) and ten athletes from sports boarding school (soccer n = 4; boxing n = 1; weight lifting n = 1; wrestling n = 3; triathlon n = 1). They performed their sport on a top national level. The experimental group trained on average 16.18 hours per week and the control group 16.20 hours per week. There were no significant differences at baseline between experimental and control group except for self-efficacy (p = 0.007). Baseline characteristics are summarized in Table 2.

[Table 2 near here]

Instruments Socio-demographic questionnaire.

characteristics

Participants

were

completed

assessed self-report

using

a

self-developed

questionnaires

of

socio-

demographic characteristics at baseline (T0). In addition, the following instruments were used: Trier Inventory for the Assessment of Chronic Stress (TICS) The TICS was used to assess perceived stress (Schulz & Schlotz 1999). Incidence of experienced stressful situations over the past month was retrieved. The questionnaire measures nine subscales: work overload, social overload, pressure to perform, work discontent, excessive demands at work, lack of social recognition, social tensions, social isolation, chronic worrying. Answers are given on a five-point rating scale ranging from never (0) to very often (5). The questionnaire is standardized for athletes from the age of 16 years. Cronbach’s α ranges between 0.84 and 0.91 (M = 0.87) (Schulz et al. 2004). 7

General Self-Efficacy Scale - German version (SE) The SE assesses optimistic self-beliefs in coping with difficulties and demands (Schwarzer & Jerusalem 1995). The ten items are answered on a 4-point rating scale ranging from not at all true (1) to exactly true (4). Internal consistency (Cronbach’s α) for this scale is 0.92 (Hinz et al. 2006).

Test of knowledge The test of knowledge includes 26 items on different topics of stress and stress prevention that are answered in a dichotomous format "true" or "false.” The test is available in two versions (A and B). Participants who completed version A at T0 completed version B at T1 and vice versa. A correct answered receives a point, while a false answer does not. The total score equals the sum of all items.

Acceptance of the program Satisfaction with the program overall, its presentation and teaching methods, recommendation and its perceived usefulness was assessed with eight items via a non-standardized 6-point rating scale ranging from very good (1) to very bad (6). The evaluation questionnaire was only completed at T1.

Statistical analysis Compliance of the measured data with the normal distribution was evaluated using a visual examination of the data using Q-Q plots and the distribution of all continuous variables was determined. All data were normally distributed. Statistical comparisons on socio-demographic variables between groups and test variables were made using a one-way analysis of variance for continuous variables, chisquare-test (χ²-test) and Fisher's Exact Test for categorical variables (two-tailed

8

significance) to ensure equivalent baseline status. A series of repeated-measure ANOVAs were conducted to examine group differences in self-efficacy, knowledge, and chronic stress over time (Group X Time interactions). As our independent variables only have two factors, no post-hoc tests were calculated. Paired t-tests were used to evaluate the differences in means for continuous normally distributed variables for both the experimental and control group before and after the intervention. The significance level was set to p < .05. Data analysis was conducted using SPSS, version 23 (IBM, 2013).

Results Differences in the above mentioned demographics were not significant between the groups. ANOVA results on average self-efficacy, knowledge and chronic stress scores between the groups at baseline are presented in Table 2. The groups showed a significant difference at baseline in self-efficacy (p = 0.007). Furthermore, repeated-measure ANOVAs revealed main effects for group [F (1, 54) = 7.60; p = 0.01] and time [F(1, 54) = 4.49; p = 0.03)] with regard to self-efficacy but no time x group interaction effect [F(1, 54) = 1.66; p = 0.20]. Regarding knowledge, again a main group [F(1, 53) = 15.13; p < 0.001] and a main time effect [F(1, 53) = 16.98; p < 0.001] were found. In addition, there was a trend for a significant time x group effect [F(1, 53) = 2.93; p=0.09] in knowledge. Finally, the experience of social tensions showed a time effect [F(1, 53) = 4.93; p = 0.03], but no group effect [F(1, 53) = 1.25; p = 0.27] and no time x group interaction F(1, 53) = 0.01; p = 0.94].. Table 3 provides a summary for the results from the repeated measure analyses

[Table 3 near here]

The paired t-tests showed significant improvements in self-efficacy and knowledge for the participants of the experimental group after intervention. No significant

9

effects were found in the control group. Table 4 shows the effects in SE and TICSscores after the intervention for both groups. [Table 4 near here] Figure 1 and Figure 2 show the most interesting results of participants’ ratings in regard to their perception of the program’s usefulness and recommendation evaluated via a 6-items rating scale. 56.7% agreed with the statement, that the program was very useful to them as reflected in scores of 1 or 2. When asked whether they would recommend the training to others, 47.4% answered with 2 and 15.8% with 1. [Figure 1 near here] [Figure 2 near here]

Discussion Our stress prevention program showed a positive trend for enhancing stress-related knowledge. The paired t-test in the experimental group also indicated a possible positive effect on self-efficacy. No significant effect was found for perceived stress. These results are widely consistent with those reported from previous studies of other groups on stress management in athletes and non-athletes. In the general population, stress management programs have shown significant effects on coping and well-being right after the intervention and half a year later (Kaluza, 1998, 1999). Knowledge about stress and coping was reported to be positively influenced by a stress prevention training for adolescents, whereas stress symptoms were not reduced (Beyer & Lohaus 2006). Regarding interventions for elite athletes, Sallen and Richartz (2014), who conducted a program with 173 athletes attending school, also reported an improvement of knowledge about stress. They found small significant effect sizes for more flexible coping skills and feeling less stressed in

10

difficult situations. Furthermore, perceived stress and self-efficacy were found to be improved on a descriptive level, but not significantly (Sallen & Richartz 2014). Our results appear to confirm the positive effect of a prevention program on stressrelated knowledge, but indicate that it had less impact on self-efficacy with improvement only found in the pre/post comparison but not when controlling for the non-treated comparison group. As self-efficacy has been reported to affect perceived stress in a favorable way (Bandura et al. 1988) and a low sense of efficacy has been shown to produce depression and anxiety (Bandura 1993) as well as having been connected to severe depressive symptoms and anxiety in adolescents (Muris 2002), future programs for elite athletes should place a stronger focus on this aspect. Elite athletes might be particularly motivated to increase their self-efficacy since - although not intended – an increase in self-efficacy has been shown to also have beneficial consequences on sport performance (Moritz et al. 2000). Furthermore, the majority of participants in the experimental group showed a good overall satisfaction with the program. They rated the usefulness of the program as good and the majority would recommend it to other elite athletes. Moreover, the practicability of this short intervention with sessions lasting no longer than 30 minutes has proven to be good. The low time scope made it possible for participating athletes and coaches to include the program in their weekly routine. Correspondingly, on the one hand, we did not want a stress prevention program to be the cause of even more stress. On the other hand, the limited scope of time did not allow the consolidated training of further elements, such as relaxation techniques, mindfulness or cognitive strategies. Hence, we might have missed more effects as a result.

Limitations and future research The relevance of these preliminary results is limited due to the small sample size of our study. Statistical analysis was also limited by differences at baseline between the groups. Also, a randomization did not take place and data were not corrected for multiple testing. Only recruiting elite athletes on a top national level was not easy.

11

However, we believed this group to experience the highest stress due to training load, traveling, and pressure. Further studies are needed with a larger sample size, more careful matching and randomization to control for the effects found. In order to test for long-lasting results, a follow-up assessment after at least six months should be implemented. If these positive effects can be confirmed in a larger sample, the continuous instalment of a stress prevention program at the Olympic Training Centers could be reasonable and established in cooperation with the sport psychologists working directly with the elite athletes. In future studies, it would be important to also address coaches as they play a key role in the athletes’ life. As gate keepers, by creating an autonomy supportive environment for their athletes, they can actively improve the well-being of their athletes in consequence (Adie et al. 2008).

Acknowledgement: We thank the Ministry of Science, Research and the Arts in Baden-Württemberg for funding this project.

12

References Adie, J.W., Duda, J.L., Ntoumanis, N. (2008) Autonomy support, basic need satisfaction and the optimal functioning of adult male and female sport participants: A test of basic needs theory. Motivation and Emotion 32, 189–199 Andersen, M.B., and Williams, J.M. (1999) Athletic injury, psychosocial factors and perceptual changes during stress. Journal of Sports Science 17(9),735-741 Armstrong L., VanHeest, J. (2002) The unknown mechanism of the overtraining syndrome: clues from depression and psychoneuroimmunology. Sports Medicine 32, 185-209 Bandura, A., Cioffi, D., Taylor, C.B., Brouillard, M.E. (1988) Perceived self-efficacy in coping with cognitive stressors and opioid activation. Journal of Personality and Social Psychology 55(3),479-488 Bandura, A. (1993) Perceived Self-Efficacy in Cognitive Devlopment and Functioning. Educational Psychologist 28(2), 117-148 Beyer, A., Lohaus, A. (2006) Stresspräventionstraining im Jugendalter. Hogrefe, Göttingen, Germany Breuer, C., Wicker, P. (2010) Sportökonomische Analyse der Lebenssituation von Spitzensportlern

in

Deutschland.

Sportverlag

Strauß,

Inh.

Rudolf

Strauß

Olympiaweg 1, 50933 Köln © Bundesinstitut für Sportwissenschaft, Bonn Druck: Hausdruckerei des Statistischen Bundesamtes, Zweigstelle Bonn Breuer C, Hallmann K. (2013) Dysfunktionen des Spitzensports: Doping, MatchFixing und Gesundheitsgefährdungen aus Sicht von Bevölkerung und Athleten. Bundesinstitut für Sportwissenschaften, Bonn DeFreese, J.D., Smith, A.L. (2014) Athlete social support, negative social interactions and psychological health across a competitive sport season. Journal of Sport and Exercise Psychology 36(6), 619-630 Gustafsson, H., Hassmén, P., Kenttä, G., Johansson, M. (2008) A qualitative analysis of burnout in elite Swedish athletes. Psychology of Sport and Exercise 9, 800–816 13

Hinz,

A.,

Schumacher,

J.,

Bevölkerungsrepräsentative

Albani,

C.,

Normierung

Schmid, der

G.,

Skala

Brähler, zur

E.

(2006)

Allgemeinen

Selbstwirksamkeitserwartung. Diagnostica 52, 26-32 Kaluza, G. (1998) Effekte eines kognitiv-behavioralen Stressbewältigungstrainings auf Belastungen, Bewältigung und (Wohl-) Befinden - eine randomisierte, kontrollierte prospektive Interventionsstudie in der primären Prävention. Zeitschrift für Klinische Psychologie 27(4), 234-243 Kaluza,

G.

(1999)

Sind

die

Effekte

eines

primärpräventiven

Stressbewältigungstrainings von Dauer? Eine randomisierte, kontrollierte Follow-upStudie. Zeitschrift für Gesundheitspsychologie 7, 88-95 Kessler, R.C. (1997) The effects of stressful life events on depression. Annual Review of Psychology 48, 191-214 Kleinert, J., Boss, M. und Breuer, S. (2010) Wie gesund fühlen sich junge Athleten Gesundheitsbezogene Selbsteinschätzung im Leistungssport. Momentum eJournal 1, 43-50 Moritz, S.E., Feltz, D.L., Fahrbach, K.R., Mack, D.E. (2000) The Relation of SelfEfficacy Measures to Sport Performance: A Meta-Analytic Review. Research Quarterly for Exercise and Sport, 71(3), 280-294 Muris, P. (2002) Relationships between self-efficacy and symptoms of anxiety disorders and depression in a normal adolescent sample. Personality and Individual Differences 32, 337–348 Nixdorf, I., Frank, R., Hautzinger, M., Beckmann, J. (2013) Prevalence of depressive symptoms and correlating variables among German elite athletes. Journal of Clinical Sport Psychology 7(4), 313-326 Perna, F.M., Antoni, M.H., Baum, A., Gordon, P., Schneiderman, N. (2003) Cognitive behavioral stress managment effects on injury and illness among competitive athletes: A randomized clinical trial. Annals of Behavioral Medicine, 25(1), 66-73

14

Richartz, A., Albert, K., Sallen, J., Hoffmann, K. (2010) Chronische Belastungen und persönliche Ziele in Leistungssport- und Bildungskarriere. In Bundesinstitut für Sportwissenschaft (Hrsg.), BISp-Jahrbuch Forschungsförderung 2009/10,307-313, Bonn Rumbold, J.L., Fletcher, D., and Daniels, K. (2012) A systematic review of stress management interventions with sport performers. Sport, Exercise and Performance Psychology 1(3),173-193 Sallen, J. & Richartz, A. (2014) Training zur Verbesserung der Resistenz gegen chronischen Stress im Spitzensport: Entwicklung, Durchführung und Evaluation eines Gruppeninterventionsprogramms. In Bundesinstitut für Sportwissenschaft (Hrsg.), BISp-Jahrbuch Forschungsförderung 2013/14, 193-198, Bonn Schulz, P., Schlotz, W. (1999) Trierer Inventar zur Erfassung von chronischem Streß (TICS): Skalenkonstruktion, teststatistische Überprüfung und Validierung der Skala Arbeitsüberlastung. Diagnostica 45(1), 8-19 Schulz, P., Schlotz, W. und Becker, P. (2004) Das Trierer Inventar zum chronischen Stress, TICS Version 3. Göttingen Hogrefe Schwarzer, R., Jerusalem, M. (1995) Generalized Self-Efficacy scale. In J. Weinman, S. Wright, & M. Johnston, Measures in health psychology: A user’s portfolio. Causal and control beliefs, 35- 37. Windsor, England: NFER-NELSON Yang, J., Peek-Asa, C., Corlette, J.D., Cheng, G., Foster, D.T., Albright, J. (2007) Prevalence of and risk factors associated with symptoms of depression in competitive collegiate student athletes. Clinical Journal of Sports Medicine 17(6), 481-487

15

FIGURES

Rating of Usefulness Percent of participants

35 30

27

29.7

32.4

25 20 15 10

5.4

5.4

5

0

0 1 (totally agree)

2

3

4

5

6 (totally disagree)

Rating of usefulness in school grades

Figure 1. Rating of usefulness of the prevention program in school grades

Percent of participants

Recommendation of the stress prevention program 50 40 30 47.4

20 10

21.1

15.8

10.5

2.6

4

5

0 1 (totally agree)

2

3

Recommendation in school grades

Figure 2. Recommendation oft the prevention program in school grades

16

0 6 (totally disagree)

TABLES

Session 1

Session 2

Session3

Session 4

Session 5

introduction, evaluation of stressful situations, development of stress, stress reactions relation between situation, thoughts, feelings and behavior, possibilities of intervention to prevent stress: cognition, relaxation and problem solving, chronic stress symptoms and consequences different forms of relaxation techniques, progressive muscle relaxation exercise balance, symptoms, causes, consequences and prevention of overtraining, cognitive restructuring exercise mindfulness

game, interactive knowledge transfer, homework interactive transfer of knowledge

interactive transfer of knowledge, practical exercise, CD with relaxation exercises interactive transfer of knowledge, practical exercise interactive transfer of knowledge, practical breathing and mindful eating exercise interactive transfer of knowledge

extrinsic and intrinsic motivation, autonomy, competence and relatedness as protective factors for athlete burn-out, importance of social contacts Table 1. Stress prevention program´s structure and content of sessions Session 6

17

understand development of stress, awareness of individual stress situations and symptoms inform about strategies for preventing stress, consciousness for chronic stress and negative consequences

learn about possible relaxation methods, experience progressive muscle relaxation awareness for balanced lifestyle and overtraining. practice cognitive restructuring encouraging mindfulness in the daily routine

consciousness for own motivation, encourage autonomy, competence and social contacts

Table 2. T-Test and x2-Test for Demographic and Baseline variables

Experimental

Control

group

group

Total sample

p

Sample (%)

56

28 (50.0)

28 (50)

Female (%)

40 (71.4)

21 (75.0)

19 (67.9)

.562

Age, Mean (SD)

16.93 (2.33)

17.50 (2.80)

16.36 (1.59)

.066

Sports discipline, n (%)

.581

Basketball players

15 (26.8)

9 (32.1)

6 (21.4)

Swimmers

27 (48.2)

15 (53.6)

12 (42.9)

Other athletes

14 (25.0)

4 (14.3)

10 (35.7)

16.19 (7.47)

16.18 (7.68)

16.20 (7.39)

Training in h/w, Mean (SD) Education status, n (%)

.990 .386

School students

46 (82.1)

21 (75.0)

25 (89.3)

University students

7 (12.5)

6 (21.4)

1 (3.6)

Others

3 (5.4)

1 (3.6)

2 (7.1)

Self Efficacy

29.55 (3.36)

28.29 (2.80)

30.82 (3.44)

.004

Knowledge

14.64 (4.90)

15.85 (3.93)

13.46 (5.49)

.070

TICS WO

17.07 (5.89)

18.00 (5.85)

16.14 (5.88)

.241

TICS SOO

7.43 (3.70)

7.68 (3.95)

7.18 (3.49)

.618

TICS PRESS

17.07 (4.74)

16.96 (4.48)

17.18 (5.06)

.867

TICS WD

12.75 (3.82)

12.43 (4.30)

13.07 (3.31)

.533

TICS EDW

8.43 (3.18)

9.07 (3.37)

7.79 (2.90)

.131

TICS LSR

5.88 (3.07)

5.79 (3.54)

5.96 (2.57)

.830

TICS ST

8.64 (4.07)

8.25 (3.88)

TICS SOIS

8.82 (4.55)

9.00 (4.43)

8.64 (4.79)

.773

TICS CW

7.95 (3.85)

8.50 (3.95)

7.39 (3.74)

.286

18

9.04 (4.29)

.476

Note. n: number of participants; %: valid percents; h/w: hours per week; TICS: Trier Inventory for Chronic Stress; WO: work overload; SOO: social overload; PRESS: pressure to perform; WD: work discontent; EDW: excessive demands from work; LSR: lack of social recognition; ST: social tensions; SOIS: social isolation; CW: chronic worrying

Table 3. Repeated measures Analysis of Variance for self efficacy and knowledge

Effect

SS

df

MS

F

P

Time

18.89

1

18.89

4.49

0.03

Time x Group Group Knowledge

7.00 116.04

1 1

7.00 116.04

1.66 7.60

0.20 0.01

Time Time x Group Group

266.65 45.96 372.41

1 1 1

266.65 45.96 372.41

16.98 2.93 15.13

0.00 0.09 0.00

Time

29.49

1

29.49

4.93

0.03

Time x Group

0.04

1

0.04

0.01

0.94

Group

29.57

1

29.57

1.25

0.27

SE

TICS ST

Note. SS: sum of squares; df: degrees of freedom; MS: mean square; SE: self efficacy; TICS ST: Trier Inventory for Chronic Stress: social tensions

19

Table 4. Pre-Post T-Tests of outcome variables for experimental and control group Experimental group t0

Control group

t1

t0

t1

Scales

mean (SD)

mean (SD)

Sig.

mean (SD)

mean (SD)

Sig.

SE

28.29 (2.80)

29.61 (3.38)

t(26) = - 2.30*

30.82 (3.44)

31.14 (2.80)

t(27) = - 0.62

Knowled ge

15.85 (3.93)

20.26 (2.47)

t(26) = - 5.00***

13.46 (5.49)

15.29 (5.31)

t(27) = - 1.50

TICS WO

18.22 (5.84)

16.48 (6.19)

t(26) = 1.82

16.14 (5.88)

15.86 (8.06)

t(27) = 0.19

TICS SOO

7.48 (3.89)

6.67 (3.36)

t(26) = 1.08

7.18 (3.49)

6.68 (3.41)

t(27) = 1.08

TICS PRESS

17.07 (4.53)

15.74 (5.26)

t(26) = 1.45

17.18 (5.06)

17.18 (5.52)

t(27) = 0.00

TICS WD

12.48 (4.37)

11.22 (4.72)

t(26) = 1.62

13.07 (3.31)

13.54 (4.39)

t(27) = - 0.49

TICS EDW

9.07 (3.43)

8.59 (4.09)

t(26) = 0.63

7.79 (2.90)

8.00 (3.22)

t(27) = - 0.31

TICS LSR

5.78 (3.61)

5.37 (3.07)

t(26) = 0.59

5.96 (2.57)

6.00 (2.51)

t(27) = - 0.08

TICS ST

7.96 (3.64)

6.96 (3.64)

t(26) = 1.40

9.04 (4.29)

7.96 (3.44)

t(27) = 1.78

TICS SOIS

9.00 (4.51)

7.85 (4.53)

t(26) = 1.75

8.64 (4.79)

8.04 (5.35)

t(27) = 0.61

TICS CW

8.37 (3.96)

8.15 (3.52)

t(26) = 0.33

7.39 (3.74)

6.82 (2.83)

t(27) = 1.00

Note. d: Cohen's d; *: indicates a significant correlation on the 0.05 level; **: indicates a significant correlation on the 0.01 level; ***: indicates a significant correlation on the 0.001 level; t1: Pretest; t2: Posttest; SD: Standard Deviation; Sig: significant test; SE: self efficacy; TICS: Trier Inventory for Chronic Stress; WO: work overload; SOO: social overload; PRESS: pressure to perform; WD: work discontent; EDW: excessive demands from work; LSR: lack of social recognition; ST: social tensions; SOIS: social isolation; CW: chronic worrying

20