University of Ghana http://ugspace.ug.edu.gh DEPARTMENT OF PSYCHOLOGY UNIVERSITY OF GHANA GHANAIAN FOOTBALLERS WITH CAREER THREATENING INJURIES: EXPLORING LIVED EXPERIENCES BY CECILIA OWUSU PREMPEH 10192467 THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON, IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE AWARD OF MPHIL CLINICAL PSYCHOLOGY DEGREE JULY 2019 University of Ghana http://ugspace.ug.edu.gh DECLARATION This is to certify that this thesis is the result of research carried out by CECILIA OWUSU PREMPEH towards the award of the MPhil Clinical Psychology Degree in the Department of Psychology, University of Ghana. …………………………………………....... CECILIA OWUSU PREMPEH (STUDENT) ……………………………........................... DATE ……………………………… ………………………………. PROF. JOSEPH OSAFO DR. ANNABELLA OSEI-TUTU (PRINCIPAL SUPERVISOR) (CO-SUPERVISOR) ……………………………… ………………………………. DATE DATE i University of Ghana http://ugspace.ug.edu.gh ABSTRACT The extant literature have examined the prevalence of injuries among a number of sporting disciplines using quantitative methods. Few studies have explored the lived experiences of rugby and ice hockey players, employing qualitative methods. A review of literature shows that little or no study has been conducted on the lived experiences of footballers with career threatening injuries especially within the African context. The study sought to explore the psychosocial problems male Ghanaian footballers with career threatening injuries face, how the injuries affect their wellbeing, the resources available for recovery, and how footballers cope with those problems. To achieve these aims, a qualitative research design with semi-structured interviews was adopted. Thirty one (31) male Ghanaian footballers with career threatening injuries living within Greater Accra region or Ashanti region were purposively and conveniently sampled. Interpretative Phenomenological Analysis (IPA) was used in analysing the data. Four (4) superordinate themes were extracted from the data. Participants’ responses generally clustered around mode of sustaining injury, emotions following injury, mode of treatment, and coping strategies. Ghanaian footballers believed that their injuries were due to the nature of the pitch. They sustained injuries through body contact and non-contact mediums. Moreover, the injuries caused them emotional distress and some psychological problems. In dealing with an injury, participants often resorted to medical (orthodox), herbal medicine or a mixture of treatments. Prayer, social support from friends and family, and normalising of injury helped them to cope with their injury. It is recommended that clubs urgently hire the services of psychologists and counsellors to take care of the psychological needs of players who suffer career threatening injuries. Regulatory bodies in Ghana should ensure that clubs with proper or standard pitches and medical facilities are licensed to operate. ii University of Ghana http://ugspace.ug.edu.gh DEDICATION This thesis is dedicated to God Almighty for seeing me through to the end of this course. May His name be praised. To my Dad Sir. Kt. Cmdr. Lawrence Owusu Prempeh for being a strong pillar behind me. To Nana Agyenim Boateng I, who motivated me to keep my dreams alive and believe in my capabilities. To my children Lawrence Bentil for his unflinching support to see me through and Brianna Nana Yaa Saah Boateng, my soulmate, who has been by my side throughout the entire study period. May God richly bless all of you. iii University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGMENT I would like to express my sincere gratitude to my supervisors Professor Joseph Osafo and Dr. Annabella Osei-Tutu for their continuous support of my thesis. I could not have had better supervisors and mentors. To my wonderful lecturers who supported me in various ways to see to the success of this work, I am deeply grateful. The success and final outcome of this project required a lot of guidance and help from many people. I am extremely grateful to Abishai Anlimah, Michael Ansah Nyarko, Feikoab Parimah, Ernest Owusu Ansah and Ms. Monica Foadey. I thank my fellow Mphil colleagues for the stimulating discussions and sleepless nights we worked together before deadlines, the fun, inspiring guidance, constructive criticisms and friendly advice we shared in the last two years. To my friends who spurred me on in those challenging days, I say thank you. Finally, I must express my profound appreciation to my wonderful family for providing me with unfailing support and continuous encouragement throughout my years of study. This accomplishment would not have been possible without you. Thank you. God bless you all iv University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENTS DECLARATION ..................................................................................................................................... I ABSTRACT ............................................................................................................................................ II ACKNOWLEDGMENT ........................................................................................................................ IV TABLE OF CONTENTS ........................................................................................................................ V LIST OF TABLES ................................................................................................................................ VII CHAPTER ONE ..................................................................................................................................... 1 INTRODUCTION .................................................................................................................................. 1 1.0 BACKGROUND OF THE STUDY ....................................................................................................... 1 1.1 STATEMENT OF THE PROBLEM ..................................................................................................... 5 1.2 RELEVANCE OF THE STUDY .......................................................................................................... 8 1.3 AIMS AND OBJECTIVES OF THE STUDY ......................................................................................... 8 CHAPTER TWO .................................................................................................................................... 9 LITERATURE REVIEW ....................................................................................................................... 9 2.0 INTRODUCTION ............................................................................................................................. 9 2.1 THEORETICAL FRAMEWORK ........................................................................................................ 9 2.3 RATIONALE OF THE STUDY ......................................................................................................... 17 2.4 RESEARCH QUESTIONS ................................................................................................................ 18 CHAPTER THREE .............................................................................................................................. 19 METHODOLOGY ............................................................................................................................... 19 3.0 INTRODUCTION ........................................................................................................................... 19 3.1 RESEARCH DESIGN AND METHODOLOGICAL UNDERPINNING .................................................... 19 3.2 STUDY SETTING, PARTICIPANT RECRUITMENT AND SELECTION ............................................... 21 3.3 INTERVIEW GUIDE ....................................................................................................................... 22 3.4 PROCEDURE ................................................................................................................................. 23 3.5 DATA ANALYSIS ........................................................................................................................... 23 3.6 VALIDITY AND REFLEXIVITY ...................................................................................................... 24 3.7 ETHICAL ISSUES .......................................................................................................................... 25 CHAPTER FOUR ................................................................................................................................ 26 RESULTS ............................................................................................................................................. 26 4.0 INTRODUCTION ........................................................................................................................... 26 4.1 DEMOGRAPHIC CHARACTERISTICS OF PARTICIPANTS ............................................................. 26 4.3 MODES OF SUSTAINING INJURY .................................................................................................. 29 4.4 EMOTIONS FOLLOWING INJURY ................................................................................................. 36 4.5 MODE OF TREATMENT ................................................................................................................ 42 4.6 COPING STRATEGIES ................................................................................................................... 49 CHAPTER FIVE .................................................................................................................................. 53 DISCUSSION, RECOMMENDATIONS AND CONCLUSION ......................................................... 53 5.0 INTRODUCTION ........................................................................................................................... 53 5.1 DISCUSSION ................................................................................................................................. 53 v University of Ghana http://ugspace.ug.edu.gh 5.2 IMPLICATIONS OF FINDINGS ....................................................................................................... 60 5.3 LIMITATIONS OF THE STUDY....................................................................................................... 61 5.4 CONCLUSION ............................................................................................................................... 62 REFERENCES ..................................................................................................................................... 64 APPENDICES ...................................................................................................................................... 76 INTERVIEW GUIDE .................................................................................................................................... 76 INTRODUCTORY LETTER FROM DEPARTMENT ........................................................................................ 79 LETTER FROM ETHICS COMMITTEE FOR THE HUMANITIES (ECH) ...................................................... 80 vi University of Ghana http://ugspace.ug.edu.gh LIST OF TABLES Table 1 Demographic characteristics of participants (N=31) .......................................... 27 Table 2 Superordinate and subordinate themes (N=31) .................................................. 29 vii University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE INTRODUCTION 1.0 Background of the study Whereas 39% of ankle sprain injuries are sustained during non-contact-mechanisms, 54% are observed during tackle scenarios (Farquharson & Greig, 2017). Akodu et al. (2012) found that, out of the 89 injuries recorded during the 2011 West African Football Union (WAFU) tournament, 82% of the injuries were sustained through contact with another player, with 19.1% resulting in time-loss (loss of competition activity). Major muscle groups of the lower extremities account for 92% of muscle injuries, with 23%, 13%, 37%, and 17% being the abductors, the calf muscles, hamstring, and quadriceps respectively (Ekstrand, Hagglund, & Walden, 2011; Pfirrmann, Herbert, Ingelfinger, Simon,& Tug, 2016; Svensson, Alricsson, Karmeback, Magounakis, & Warner, 2016). High injury incidence in football and other sporting disciplnes is a function of contact between players and substantial physiological demands (Mauntel et al., 2017; Shalaj et al., 2016). Rago et al. (2018) noted that during a football match, high-intensity actions decrease, leading to match-induced fatigue that brings about muscle damage after a football match (Pavin et al., 2018). A common injury in football is ankle sprain (Farquharson, & Greig, 2017; Smpokos, Mourikis, Theos, & Linardakis, 2018). Injuries to muscles, bone, knees, hamstring, joint ligament, nerve, tendon, and soft tissue are caused by repetitive stress or direct trauma (Adjei, Moses, Nutakor, & Gyinaye, 2015; Longo et al., 2010). The ever so threatening problem of whether one can reach the earlier levels of performances again, can affect his or her quality of life (Gouttebarge, Aoki & Kerkhoffs, 2018). Involuntary retirement or break due to a career-ending injury is difficult to deal with due to its unexpected nature (Wylleman, Alfermann, & Lavallee, 2004). This in turn 1 University of Ghana http://ugspace.ug.edu.gh causes stress (Kerr & Dacyshyn, 2000; Stoltenburg, Kamphoff & Bremer, 2011), thereby affecting the quality of life of footballers. Also, match exposure, minutes of playing, poor running performance, recurrence of injury, and days of rehabilitation have been noted to be risk factors for injury (Bengtsson, Ekstrand, & Hagglund, 2013; Del Coso, Herrero, & Salinero, 2018; Ekstrand et al, 2011; Hagglund, Walden, & Ekstrand, 2012; Stubbe et al. 2015). Contrary to Woods et al. (2004) who indicated that defenders sustain 15% more hamstring strains compared with forwards, Dadebo, White, and George (2004) showed that forwards sustained 10% superior amount of hamstring strains. In addition, Hagglund, Walden, and Ekstrand (2005), and Jacobson and Tegner (2007) showed that injury risk in football is higher in male adults than in female adults. These injuries stem from a complex interaction of both intrinsic and extrinsic risk factors (Akinbo, Salau, Odebiyi, & Ibeabuchi, 2007). Culture of risk Frey (1991) used the term “a culture of risk” to explain an environment within which athletes normally compete or train injured and take risks in order to succeed. The “culture of risk” legitimizes an athlete’s acceptance of pain, aggression and risk-taking behaviour as a normal aspect of participation (Safai, 2003). This has been established in a number of studies (Crossman, 1977; Frey, 1991; Hale, 2008; Howe, 2001; Johnson, 2000; Leddy, Lambert, & Ogles, 1994; Pargman, 1999; Roderick, Waddington, & Parker, 2000; Tracey, 2003; Young, White & Mcteer, 1994). Persons desiring to be professional or elite athletes often give in to a sport ethic that encourages long hours of training, risk taking, pushing through pain, and long playing seasons in order to succeed (Messner, Dunbar, & Hunt, 2000; Richardson, Anderson, &Morris, 2008). Most under-recovered or injured athletes try to continue competing due to the possibility of professional pride, personal ambition or 2 University of Ghana http://ugspace.ug.edu.gh team pressure, guilt, or being replaced (McGannon, Cunningham, & Schinke, 2013). Young et al. (1994) suggested that money, praise, attention, and the perceived/real risk of being dropped from the team are some of the incentives that encourage athletes to take greater risks in competition/training, and to play in the state of injury. Psychosocial well-being of sportsmen Depression as defined by the National Institute of Mental Health (2012) is “a common but serious mental illness typically marked by sad or anxious feelings. Untreated depression lasts for a long time, interferes with day-to-day activities, and is much more than just being ‘a little down’ or ‘feeling blue’.” (p. 2). Gulliver, Griffiths, Mackinnon, Batterham, and Stanimirovic (2015) noted that recurrent or severe injuries in professional footballers are deemed to be major psychosocial and physical stressors. Warriner, and Lavallee (2008) observed that severe injuries are likely to trigger involuntary or early retirement from professional football, becoming a probable risk for psychosocial and mental health problems after retirement. Kristiansen, Halvari and Roberts (2012) noted that public and media interest in players, and organisational pressure with regards to financial and sporting success are some sources of the psychosocial stressors professional footballers encounter. As well, fear, anxiety, anger, depression, decrease in vigour, and confusion are some common emotions recorded after an injury (Tracey, 2003). Clement and Shannon (2011) explained that athletes’ re-evaluation of their capabilities, their personal identity, and their role on the team are the sources of these emotions. Quality of life (QOL) is a general well-being of individuals and societies, outlining negative and positive features of life, which observes life satisfaction, including physical and mental health, and social belonging (family, friends, and religious beliefs) (Barcaccia, Esposito, Matarese, Bertolaso & De Marinis, 2013). Stoltenburg et al. (2011) showed that 3 University of Ghana http://ugspace.ug.edu.gh sportsmen experience a wide array of both negative and positive emotions triggered by the understanding that their sport career had been truncated. Other works had previously suggested that the way an athlete copes with the end of her or his career can be a determining factor in how an athlete moves out of their respective sport (Gardner & Moore, 2006). Freeman, Coffee, and Rees (2011, p.54) defined perceived social support within the athletic context to be “one’s potential access to social support and is a support recipient’s subjective judgement that friends, team-mates, and coaches would provide assistance if needed”. Anderson and Williams (1988) list friends, family, coaches, team-mates, and sports medicine staff to be examples of social support. Williams and Galliher (2006) asserted that high levels of social support, physical activity, and self-esteem often protect athletes from depression. Wheeler (2007) adds that social support is considered a protective influence on mood, physical function of the body, and overall well-being. Though emotional social support has proven to be an effective form of support for athletes, informational social support is the most preferred form of social support later in the injury process (Yang, Peek- Asa, Lowe, Heiden, & Foster, 2010). Spiritual or religious coping Religiosity is a multifaceted concept encompassing emotional, cognitive, motivational as well as behavioural dimensions (Hackney & Sanders, 2003). Richards and Bergin (1997) added that it is a subset of spirituality since one could be spiritual and not be religious. However, it is also possible to be religious and not be spiritual. Whereas being religious entails adopting to particular sets of religious creed, spirituality connotes a knowledge and connection with the transcendent (Rusu & Turliuc, 2011). There is a great impact of religion on the individual, since it is considered a vital source of social support (Frey & 4 University of Ghana http://ugspace.ug.edu.gh Stutzer, 2002). Krause and Wulff (2005) have suggested that church-based relationships could advance one’s sense of belonging and consequently enhance his or her mental and physical health. 1.1 Statement of the problem Sportsmen in Africa suffer serious injuries. For example, Akodu et al. (2012) indicated that 89 injuries were recorded during the 2011 WAFU cup tournament. They showed that 82% of the injuries were sustained through contact with another player. Recently, Omoniyi, Kwaku, and Francis (2016) found that there was an increase in the number of injuries among footballers in Ghana. They also revealed that 83 midfielders in the premier league suffered serious injuries, with 20.5% sustaining knee injuries. These injuries stem from a complex interaction of both intrinsic and extrinsic risk factors (Akinbo, Salau, Odebiyi, & Ibeabuchi, 2007), with consequences ranging from re-injury to career-ending (Kohrt, Bloomfirld, Little, Nelson, & Yingling, 2004). Consequently, Omoniyi et al. (2016) suggested that the provision of preventive therapy could sustain the careers of upcoming footballers. It has been suggested that injuries sustained by Ghanaian footballers are often addressed using biomedical approaches (Omoniyi et al., 2016). However, athletic performance is affected by numerous factors including physiological, biomechanical, and psychological factors (Aritan, 2015). In a resource poor setting as Ghana, the preponderance of biomedical healing systems might obscure the psychological challenges athletes go through and thus sideline the role of psychocentric practitioners such as psychologists, counsellors, psychotherapists, and psychiatrists. Pain from injuries, the duration of treatment, cost of treatment, perceived lack of social support, feelings of hopelessness following the injury etc., can all create a psychological distress in the athlete. The 5 University of Ghana http://ugspace.ug.edu.gh lamentation of Ali Jarrah, who was a prodigy in his days is one of the best illustrations one can have. He said: “I just wanted to share this with friends. Life has never treated me fairly; siblings and friends have also never treated me fairly. Those you treat well will turn their backs on you. Why will people judge you with your disability and turn their backs on you? This world is a journey, why will people suffer and toil which is no fault of theirs. Friends and brothers who are supposed to comfort that fellow neglects him. This is a little story I have to share with you, friends. I started as a footballer (goalkeeper to be specific) I’ve played 3 juvenile World Cups and 1 African Cup of Nations. I’ve won one juvenile world cup, two silvers and one African Cup of Nations. I also played for Accra Hearts of Oak. I won all the 3 awards in the 1992/1993 season. I got paralyzed in 1993. I started training goalkeepers to give back to the society, which I’ve helped over 30 goalkeepers to be in the premiership and the national teams both male and female. I coach people with disability; I’ve been able to help 7 amputees to play in Turkey. Why is it that I’ve been able to change peoples’ lives and no one cares about me? I am dying slowly. Ministers, philanthropists, football authorities executives, parliamentarians can’t they come to my aid? In Ghana, if you don’t have a push you can’t survive. Day in and out, I am heading towards my grave. They will wait till I die before they remember me. If I got paralyzed at 17 dying for my nation, what does the nation expect me to do now after 23 years? I leave this to the world to judge. You can share my little story amongst friends and brothers so they know. When I die, I died because of pain” (Ghanaweb, 2015). 6 University of Ghana http://ugspace.ug.edu.gh Another promising Ghanaian footballer who sustained an injury that kept him away from the field of play for over nine years is Opoku Agyemang who tore his knee ligament after an impressive performance during the 2010 African Cup of Nations in Angola. He also played for the Ghana national team at all age levels: the 2005 U-17 team, and went on to win the 2009 FIFA U-20 World Cup in Egypt. His story also gives us a hint as to the challenges footballers with career threatening injuries go through; “Despite being out these past nine years, I have always felt confident that I will recover fully and play again. I’m still on rehabilitation full of hope that I return soon,… Growing up, I had dreams of playing top level football… I will be 30 in June (2019) and I have given up on that because the agents shy away saying age is not on my side coupled with the fact that I have been out for over 8 years. Like I said, I have not given up on playing again. When I finally feel there is no chance, I will surely announce the end of my playing career. “I love to play football. It is my source of happiness and I give it my all…,” (Ghanaweb, 2019) The present study is thus an attempt to examine some of these psycho-emotional factors and provide evidence that will guide a holistic provision of intervention and treatment for footballers in Ghana. The study will seek to bring into the treatment package for footballers the role of psychocentric practitioners. Further, approaches that have been used to study the experiences of injured players have been predominantly quantitative. Studies that investigated incidence of injuries sustained by athletes employed systematic reviews which make it quite difficult to firmly conclude that the rates and types of injuries recorded are true reflections of the picture on the ground (e.g., Del Buono, Volpin t, & Maffulli, 2014; Robertson & Wood, 2015). This method is 7 University of Ghana http://ugspace.ug.edu.gh likely to exclude other relevant studies due to the search words or phrases that are used. In essence, there is the need to conduct studies that will explore the lived experiences of footballers with career threatening injuries. 1.2 Relevance of the study To the best of my knowledge, the study is the first of its kind that seeks to explore the experiences of Ghanaian footballers with career threatening injuries. Thus, it will add to the extant literature on the career threatening injuries worldwide, and the experiences of footballers with career threatening injuries in Ghana. This will provide the basis upon which other studies could be done in the area of footballers with career threatening injuries. Further, the study will provide knowledge about what footballers with career threatening injuries go through, highlighting the psychological peoblems they encounter during injuries, and the recovery process. Such knowledge will inform clinical interventions. 1.3 Aims and Objectives of the study The study seeks to explore the lived experiences of footballers with career threatening injuries in Ghana. Specifically, the study seeks to explore; 1. The psychosocial problems footballers with career threatening injuries in Ghana face. 2. How these problems affect their well-being. 3. Resources accessible for rehabilitation. 4. The kinds of coping strategies they adopt in dealing with those psychosocial problems. 8 University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO LITERATURE REVIEW 2.0 Introduction The chapter addresses five main issues. It starts by providing the theoretical underpinnings of the study. Two theories are explained: cognitive appraisal model of stress, and the Africultural coping theory. This is followed by the review of related studies, from which the rationale of the study is derived and the research questions of the study are stated. 2.1 Theoretical framework Cognitive appraisal model of stress According to Lazarus and Folkman (1984), stress is a person-situation interaction. Thus, it depends on an individual’s subjective cognitive judgment, suggesting that events or situations are not stressful in themselves. They proposed that a situation or an event becomes stressful when a person subjectively appraises it as threatening, harmful, or requiring of available resources. It therefore suggests that, a mismatch between the changeability of the stressor currently facing an individual and the appropriate form of coping to be applied to the stressor makes coping quite difficult. Lazarus (1991) posits that athletes can have primary and secondary cognitive appraisals. The former entails a type of cost-benefit-analysis to evaluate the likely consequences of the injury, whilst the latter appraises the coping resources and strategies the athlete possesses to deal with the consequences of the injury. Lazarus (1991) and Wiese-Bjornstal, Smith, Shaffer, and Morrey (1998) suggest that both the primary and secondary appraisals are expected to affect the perceived stress of the injury, the emotional response to it, and the resultant behavioural reactions of the athlete. Since the association is not necessarily a unidirectional one, Walker, Thatcher and Lavallee (2006) note that athletes’ appraisals can 9 University of Ghana http://ugspace.ug.edu.gh directly affect their behavioural reactions without they perceiving their injury as manageable (which is an emotional response). On the other hand, behavioural reactions can also result in cognitive reappraisals which are also likely to influence athletes’ emotional reactions. Per this model, a footballer assesses what is at risk in his situation during the primary stage. Footballers’ fear of losing bonuses, fear of losing playing time, the distress of being unable to engage in the sport, and worry of financial cost of injury are examples of the thought process at this stage (Wheeler, 2007). Howbeit, footballers are likely to appraise their injuries differently. At the secondary appraisal stage, the footballer asks himself whether he has control over some aspects of the injury situation, and whether or not the situation can be changed to make things less threatening or stressful. A footballer at this stage also assesses whether he is capable of handling the emotions that accompany the overall response to the injury (Wheeler, 2007). The type of coping strategy most appropriate for the specific situation is largely dependent on a footballer’s response to these questions. Africultural coping theory The Africultural coping theory (Utsey, Adams, & Bolden, 2000) explains the cultural specific coping behaviours adopted by people of African descent. It makes evident the African-centred approach, mirrored in the values, customs, and attitudes that are drawn from an African philosophical framework and is vital for comprehending the behaviour of individuals of African descent (Asante, 1998; Azibo, 1992). African-centred philosophy postulates that everything in the world is functionally related, and people are considered as an extension of the environment. Thus, the collective consciousness amplifies the group as a natural support base (Post & Weddington, 1997). As Nobles (1986) notes, consubstantiation portrays a holistic world view where meaning 10 University of Ghana http://ugspace.ug.edu.gh is derived from the interconnectivity of events. The African believes that a human being is a force acting within an ordered universe with the capability of harmonizing with nature (Jahn, 1961). Nobles (1986) advanced the idea that harmony demands striking a balance between complementing opposites in line with the rhythms of the environment. Looking at this within the context of coping, coping behaviours will demand the capability of harmonizing with events that embody spiritual manifestations occurring within a material/physical sphere. According to this African-centred philosophical posture, coping is considered as an attempt to maintain some level of balance and harmony within the metaphysical, physical, psychological/spiritual, and communal/collective realms of human existence. Tampering with this balance or harmony results in stress. Utsey et al. (2000) demonstrated that people of African descent are likely to cope with life’s stresses in either of four ways: cognitive/emotional debriefing, spiritual-centred coping, collective coping, and ritual- centred coping. Cognitive/emotional debriefing depicts an adaptive response by individuals of African descent to manage environmental stressors, by hoping that with time things would get better. Also, spiritual-centred coping explains how prayer is used as a tool in coping, with the belief that spiritual elements and God are involved in human affairs in the universe. Collective coping is founded upon the African-based value/cultural system which places the group far above the person. Besides, ritual-centred coping requires the performance of rituals as a way of acknowledging ancestral roles in one’s life, and by paying homage to different religious deities and celebrating events. This theory will help explain why Ghanaian male footballers will resort to prayers or spiritual help in order to deal with the stressors that come along with injuries. They are also likely to derive some emotional support from their colleagues. Going by an African-centred 11 University of Ghana http://ugspace.ug.edu.gh philosophy, Ghanaian footballers are likely to believe that since everything in the world is functionally related, they have to rely on their collective consciousness which magnifies the group as a natural support base (Post & Weddington, 1997). Thus, collective coping will help throw light on why Ghanaian male footballers are likely to seek social support from their family members and friends. 2.2 Review of related literature Injuries among young footballers Clausen et al. (2014) examined the incidence of injury in adolescent female football players in Denmark. Also, they investigated the relationship between football exposure, injury risk, and playing level. The study employed a descriptive epidemiology and cohort study. Four hundred and ninety-eight (498) girls between the ages of 15 and 18, enrolled on a team participating in Danish Football Association were sampled for the study. High incidence of injury including severe injuries were recorded in adolescent female football players. Players participating frequently in football had higher injury risk compared to those with low football participation. The findings are limited to adolescent female football players, and cannot be generalised to adolescent and adult footballers within and outside Denmark. It also failed to provide in-depth information as to the types of injuries investigated, and how those injuries impact the psychological well-being of the players. The lack of depth in the information provided could be attributed to the descriptive nature of the study. An explorative one could make up for such weaknesses. Other studies that cover elite or professional football players are required to provide more depth in this direction. Besides, Khodaee, Currie, Asif and Comstock (2017) aimed at describing patterns, trends and injury rates by position, sex and athlete exposure (AE) among High School football 12 University of Ghana http://ugspace.ug.edu.gh players. With a descriptive epidemiological study, information from a national High School sports injury surveillance program for two (2) academic years was used. They found that whilst injury patterns are more similar across sexes, injury rates among High School football players vary by type of exposure and sex. This result is limited to High School football players, and does not cover elite or professional football players. The descriptive nature of the study does not also give room for depth in understanding these injury patterns among football players. Furthermore, Read, Oliver, De Ste Croix, Myer, and Lloyd (2018) evaluated the present incidence of injury, giving an update on reports published before the introduction of the Elite Player Performance Plan (EPPP). Six hundred and eight (608) football players between the ages 11 and 18 were prospectively monitored from six (6) professional football clubs with injuries recorded within a season. The most common injuries sustained in players were sprains and strains, with the ankle and knee being the most frequently injured anatomical sites. The findings do not show how these injuries threaten the career of these football players, and how they impact on their psychosocial well-being. Kuzuhara, Shibata, and Uchida (2017) sought to describe the sites, types, mechanisms and incidence of injuries during practices and games among elementary school-aged junior football players. In a descriptive epidemiology study, eighty-nine (89) football players at the U-12, U-11, and U-10 levels in five (5) community-based club teams were used. Compared to practice injury rates, game injury rates were higher in the participants. At a descriptive level, the study failed to provide reasons for the disparity in the rates of injuries recorded during practice and game. A phenomenological design could have explored the experiences of football players to know why and how they came about those injuries. Similarly, Distefano et al. (2018) examined the epidemiology of injuries sustained among 13 University of Ghana http://ugspace.ug.edu.gh football players in High School through nine (9) academic years and collegiate women football players through ten (10) academic years. A descriptive epidemiology study was conducted through an online injury surveillance from collegiate women and High School girls’ football teams. More injuries were recorded in College compared to High School, and during the competitions compared to practices. Like Kuzuhara et al. (2017), reasons why more injuries were recorded during competitions were not accounted for due to the design that was used. Injuries among adult footballers In a cohort study, Stubbe et al. (2015) examined the characteristics and incidence of injuries within the Dutch premier football league. Two hundred and seventeen (217) football players (professionals) from eight (8) teams were prospectively followed throughout the 2009/2010 football season. They indicated that there was a high risk of injury in the Dutch premier football league. Like Clausen et al. (2014), the findings cannot be generalised to other footballers outside the Netherlands. Moreover, the study only focused on the prevalence of injuries, without nuancing the psychological impact of such injuries on footballers. This could be attributed to the design that was used, limiting the extent to which the experiences of footballers with injuries could be explored. Also, Gebert et al. (2018) examined the causes, context and characteristics of injuries in non-professional football players. An analysis of seven hundred and eight (708) football injuries was performed based on retrospective telephone survey conducted with individuals who were injured while playing football and reported such injuries to the Swiss National Accident Insurance Fund. They found out that 75.4% of the injured individuals played for a club, with 30.1% of the injuries occurring within informal football play. Whereas 29.5% of all injuries were as a result of foul play, 53.0% were caused by contact. Being tackled 14 University of Ghana http://ugspace.ug.edu.gh by an opponent, and turning/twisting were noted to be the causes of injury severity. Moreover, Smpokos et al. (2018) examined the risk factors and prevalence of injuries on a cohort of one hundred and twenty-three (123) professional football players in Greek teams for three (3) consecutive seasons. About 75% of the footballers were injured with an incidence of fifty-five (55) injuries per 1000 match-playing-exposure-hours. A number of them were found to have moderate to major or severe injuries which were often traumatic. Although the study indicated that footballers experienced some trauma due to the injuries sustained, it failed to explore how footballers cope with such trauma. Incidence of injuries among footballers in Africa In Nigeria, Onakunle, Owoeye, Ajepe, Akodu and Akinbo (2016) investigated the risk factors and severity of injuries among Nigerian male national and professional football league players. With a sample of two hundred and twenty-six (226) registered footballers, self-administered questionnaires were used in eliciting the demographic characteristics of respondents, potential risk factors of injury and severity of injury. Findings were that, there was an overall injury prevalence of 18.7%. Most of the respondents reported severe injuries occurring at the joints of the knee (31.7%). The study could not furnish us with the kinds of psychosocial challenges these footballers encounter in the face of these injuries. Likewise, Adjei et al. (2015) compiled sports injuries occurrences and management techniques utilised by local sports women and men (including footballers) from Kumasi in the Ashanti region of Ghana. They indicated that there is a high prevalence of knee dislocation, ankle sprain, groin and hamstring strain sports injuries. They also established that best practices in injury prevention and management were not adhered to by the athletes. The focus of this study, as in the case of Onakunle et al. (2016) seems to be skewed towards the prevention of injuries, rather than what could be done for those who are already 15 University of Ghana http://ugspace.ug.edu.gh suffering from injuries. These findings have been supported by Omoniyi, Kwaku, and Francis (2016) who found similar rates. Wellbeing among footballers In their study of Olympic champions, "most of the participants argued that if they had not experienced certain types of stressors at specific times, including highly demanding adversities such as parental divorce, serious illness, and career-threatening injuries, they would not have won their gold medals" (Fletcher & Sakar, 2012, p.672). However, Gouttebarge, Fringes-Dresen, and Sluiter (2015) examined the psychosocial challenges and prevalence of mental health problems current and former professional footballers face. A survey was conducted with current and former professional footballers in six (6) countries. High psychosocial difficulties and mental health problems was recorded among current and former professional footballers. Also, a significant relationship was found between low social support and recent life events, and presence of mental health problems. Although the study established a relationship between social support and mental health problems, how footballers utilise social support to help them deal with their mental health problems was not explored in the study. As well, other coping strategies were not explored in the study. An exploratory study could have addressed these gaps. Matiya (2016) explored the association between coping skills, personality traits, and risk of injury. A retrospective cross-sectional survey was used. Women football players from the professional league in Zimbabwe were assessed. The findings showed that coping skills and personality, significantly predicted sporting injury among the players. Since the study was limited to female footballers, it failed to investigate the association between coping skills, personality traits, and risk of injury among male footballers. Moreover, the design 16 University of Ghana http://ugspace.ug.edu.gh used could not provide depth as to how coping skills relates to one’s risk of injury. In addition, Starzyk, Kentel, Czamara, and Krolikowska (2016) sought to evaluate the arthroscopic treatment of ankle injuries, and assess the returning time to the football field among a group of football players. To achieve this, a retrospective study of football players below 44 years who had undergone arthroscopic treatment of an ankle injury between the year 2007 and 2014 was conducted. They found that both male and female players returned to the sport, with 88.7% returning to the same level. Poor results were related to severe ankle sprain leading to fractures or ligament ruptures. Although informative, the findings does not provide us with the experiences of these footballers between the period of injury and recovery. An exploration of their experiences could have brought to light some of the psychosocial problems they face during the period of injury, and how they tried coping. 2.3 Rationale of the study Most of the studies reviewed have concentrated on young athletes (e.g., Clausen et al., 2014; Kuzuhara et al., 2017), and among professional footballers in European countries (e.g., Smpokos et al., 2018; Stubbe et al., 2015). Though some studies have been conducted in other African countries (e.g., Onakunle et al., 2016; Starzyk et al., 2016) and in Ghana (Adjei et al., 2015), the question still remains as to the kinds of psychosocial problems these footballers face, and how they cope with such challenges. Evidence so far shows that these questions have largely gone unanswered. Literature shows that the studies conducted in Africa largely focused on the prevalence of injuries among footballers, using surveys. Moreover, they generally recommended preventive measures which seem to suggest that they were not really interested in the kinds of psychosocial challenges these footballers face, and how they cope with such challenges. Injuries (especially career threatening injuries) come along with it some forms of 17 University of Ghana http://ugspace.ug.edu.gh psychosocial problems as suggested by Gouttebarge et al. (2015) that ought to be explored. Although a survey could be used to investigate such problems, exploring the lived experiences of footballers with career threatening injuries will be an added advantage by providing in-depth information. As they face these problems, it is possible that they may try coping with such problems. It is however not clear, how footballers in Ghana cope with the psychosocial problems they face. 2.4 Research questions The study seeks to answer the following research questions; 1. What are the psychosocial problems male footballers with career threatening injuries in Ghana face? 2. How do these problems affect their well-being? 3. What resources are accessible for rehabilitation? 4. What kinds of coping strategies do they adopt in dealing with those psychosocial problems? 18 University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE METHODOLOGY 3.0 Introduction The chapter begins with the research design that was used. This is followed by the study setting, sampling strategy, sample and population of the study. The instrument used is also described, and the procedure for data collection clearly outlined. Moreover, the chapter proceeds to show how the data gathered was analysed, giving some reflexive look at how the study was conducted. The chapter concludes with ethical considerations. 3.1 Research design and methodological underpinning Brannen (2005) has suggested that the kind of research design used, must satisfy methodological, practical, and theoretical purposes by addressing the research questions of a study. In the current study, the research questions essentially sought to address the experiences of participants with regards to career threatening injuries they sustain and how they cope. Hence, a qualitative research design was adopted with semi-structured interviews. The semi-structured interviews was in satisfying the methodological as well since it resonates with the theoretical underpinnings of Interpretative Phenomenological Analysis (IPA) (Smith, Flowers, & Larkin, 2009). IPA is “concerned with the detailed examination of personal lived experiences, the meaning of experience to participants and how participants make sense of that experience” (Smith, 2011, p.9). Three theoretical principles underlie IPA. Firstly it respects the participant’s own perspectives on their experiences (Husserl, 1970) and hence phenomenological. The phenomenon in this case is career threatening injury. Flick (2006) puts forward that participants possess a complex repertoire of knowledge which is subjective. Putting this into perspective, footballers have a stock of knowledge about career 19 University of Ghana http://ugspace.ug.edu.gh threatening injuries worth exploring. The phenomenological part of the IPA explores what career threatening injuries represents for individuals in their context in order to appropriately explain it from the participants’ perspectives (Laverty, 2003). This was attained by deeply engaging the participants during the interviews by listening attentively and probing rigorously to learn more about their life-world (Smith et al., 2009). A lot of effort went into establishing rapport and making the participants comfortable to narrate their experiences of career threatening injuries in football and in their relationship with others. Also, IPA is committed to an idiographic level of analysis where the meaning of an experience and its significance to a particular participant is recognised. It acknowledges the value of the particular rather than the general (Larkin & Thompson, 2012). Idiography, which is commitment to the particular, operates at two levels. Firstly, one has to be deeply engaged with the particular phenomenon (such as career threatening injury) in order to allow for in-depth analysis (Smith et al., 2009). At the other level, commitment is made towards comprehending how a particular phenomenon like career threatening injuries is understood from the position of particular individuals in a particular context (Smith et al., 2009). In the study, male Ghanaian footballers from different divisions were interviewed and engaged in a way that afforded the researcher the opportunity to understand career threatening injuries from their context. For example, the researcher needed to engage with those in the premier league and foreign based, at a certain level different from those in the second division. The experiences of these groups of footballers are quite different since they play under different conditions and structures. Some idiographic skill was required at this point to adequately engage these groups of players without missing the meaning each condition and structure under which they play threw light on the topic. 20 University of Ghana http://ugspace.ug.edu.gh Lastly, IPA is interpretative (thus, it is hermeneutic) rather than descriptive (Smith et al., 2009). From the position of IPA, the meanings given by an individual to events are very important. It explains that meaning can only be derived through an interpretative process (Biggerstaff & Thompson, 2008). Thus, the researcher can enhance an individual’s sense- making of an event and experiences through interpretation (Smith et al., 2009). There are two kinds of interpretation. Participants’ views about the phenomenon (in this case career threatening injury) represented one level of their interpretation of what the experience constitute. At another level, the researcher draws meaning from participants’ interpretation. Smith et al. (2009) labelled it as double hermeneutics. This was achieved by paraphrasing and summarising participants’ views and probing further on participants’ assertions and idiosyncrasies during the interviews. For a successful IPA interpretation, the text that is produced by the participant is crucial (Smith et al., 2009). In essence, post-interview exchanges (i.e., questions and clarifications) between participants and the researcher were captured in field notes to give more insight on participants’ views on career threatening injuries. 3.2 Study setting, participant recruitment and selection The setting of the study was the Ashanti and Greater Accra regions, where a number of football players reside. These cities are cosmopolitan in nature, and home to people from other parts of Ghana. The clubs in these two regions attract players from all over the country, and is the residential base for most of the players who ply their trade outside the country. It therefore afforded the researcher the opportunity to access players from the domestic/premier league, and professional footballers who are back into the country due to injuries. The purposive and convenience sampling strategies were used in the study. Whereas the 21 University of Ghana http://ugspace.ug.edu.gh purposive sampling technique helped the researcher in specifically accessing footballers with career threatening injuries, the convenience sampling technique made it possible for those who were available and willing, to take part in the study. Thus, the purposive ensured that specific category of cases (i.e., male footballers with career threatening injuries) were embodied in the final sample (Robinson, 2014). As Teddlie and Yu (2007) noted, the use of purposive sampling makes the transferability of findings possible. In all, thirty one (31) male footballers with career threatening injuries were sampled. The sample is adequate since depth of information rather than quantity is desired (Smith & Osborn, 2008). Only male Ghanaian footballers with career threatening injuries aged 18 years and above participated in the study. At this age, they are legally qualified to be signed onto a professional football team. 3.3 Interview guide An interview guide with main questions and probes was developed together with supervisors and used in gathering data. Before the actual interviews were conducted, the researcher did a pilot interview with one of the footballers to ensure that the interview guide elicited the needed responses that could help address the research questions of the study. Examples of questions on the guide are, “can you kindly tell me how you found yourself in this current state?”, “how did you feel when you were first told that you can’t play in the next match because of your injury?”, “what would you say are the main challenges you have faced during this period of injury?”, “how has this injury affected your life?”, “tell me how your injury sometimes make you feel in relation to your team mates, for instance about whether you may lose your position” and “can you tell me about some of the coping strategies that you have adopted so far to manage yourself?” 22 University of Ghana http://ugspace.ug.edu.gh 3.4 Procedure Upon receiving ethical approval from the Ethics Committee for Humanities (ECH), University of Ghana (protocol number: ECH 031/18-19), permission to access footballers with career threatening injuries was sought from the various football clubs within Accra and Kumasi. This was followed by visits to footballers with career threatening injuries to seek their consent to participate in the study. Arrangements were made to conduct the interviews within an environment that made it difficult for other footballers around the football pitch to listen to the interviews. The venue for the interviews were a bit distant from the football pitch. Aside from the principal investigator and research assistant, no other persons were present during the interviews. Whereas the principal investigator is female and a clinical psychology student, the research assistant is male and a graduate of psychology (with some experience in gathering qualitative data). The research assistant and principal investigator did the data collection. All participants who were chosen by their respective physiotherapists took part in the study, hence none of them dropped out of the study. The interviews were conducted in English, audio recorded, and later transcribed verbatim. Interviews lasted between twenty five (25) and thirty (30) minutes. In line with Turner, Barlow, and Ilbery (2002), the researchers stopped conducting further interviews based on emerging themes, as well as ‘consensus across views expressed’ (p. 298). 3.5 Data analysis Interpretative Phenomenological Analysis (IPA) (Reid, Flowers, & Larkin, 2005) was used in making sense of the lived experiences of Ghanaian footballers with career threatening injuries and how they cope (Smith & Osborn, 2008). This entailed transcription, bracketing and Phenomenological reduction, listening to interview for the whole sense, delineating 23 University of Ghana http://ugspace.ug.edu.gh units of general meaning, and delineating units of meaning relevant to the research questions. Per the steps outlined by Pietkiewcz and Smith (2012), the researcher (as far as possible) attempted understanding participants’ experiences from their perspective. The data was analysed through a psychological lens and interpretations done using psychological theories and concepts useful in understanding the research problems. Initially, the transcript was read a number of times. The principal investigator and research assistant immersed themselves in the data by listening to the audio recording several times, bearing in mind the atmosphere and setting of the interviews. After this, the principal investigator took note of emerging themes, and established connections or associations between the emergent themes by clustering them according to conceptual similarities. These clusters were then given descriptive labels. Finally, the themes were written up with quotes from the interviews for the purpose of exemplification, and followed by analytic comments from the principal investigator. 3.6 Validity and Reflexivity To enhance the credibility of a study, how the data is gathered, the steps followed by the researcher in managing, analysing, and reporting the data should be given due consideration (Creswell, 2014). In assessing the ‘trustworthiness’ of a study, Lincoln and Guba (1985) recommended that issues such as credibility, dependability, and confirmability be addressed, which was done in the study. Credibility was adhered to by following the procedures required in conducting interviews. Prior to the start of the study, no relationship was established with participants except the initial building of rapport before the start of the interviews. The principal investigator ensured that the relevant cases (i.e., injuries sustained by the footballers) that would help address the research questions 24 University of Ghana http://ugspace.ug.edu.gh were used. Also, both researchers asked participants for clarification on responses that were not clear to them. Moreover, both researchers did the data coding. Themes were not derived in advance, but emerged from the data. Codes from both researchers were compared for congruence, and themes discussed with the principal investigator’s supervisors to ensure that they validly reflected the data gathered. As well, to ensure dependability, an independent researcher was informed about the data collection process. There was also discussions with the independent researcher to ensure that the data analysis and reporting of the findings were accurate. This was done to ensure that the findings and interpretations were supported by the data. Such cross validation as pointed out in the literature does enhance the validity of the present study (Creswell, 2014). 3.7 Ethical issues Participants were furnished with the aims and objectives of the study. They were also assured of the confidentiality of the information they gave out, and the fact that their information was going to be used solely for academic purposes. This was to help them make an informed decision with regards to their participation. In order to keep the responses of participants anonymous, codes were used. Besides, psychological help was made available for any participant who might have needed one, during and following the interview. This is because some undesirable memories were likely to be evoked in the course of the study. Apart from such possible emotional problems, there was no physical harm associated with their participation in the study. At the end of the study, none of the participants suffered any harm, be it psychological or physical. 25 University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR RESULTS 4.0 Introduction The chapter begins with a presentation of the demographic characteristics of participants. Characteristics such as the division participants’ play, their positions, ages (both football and real ages), religious affiliation, and type of injury are clearly outlined. This is followed by a tabular and diagrammatic presentation of the key findings of the study, which are organized into superordinate and subordinate themes. They are further explained using quotes from participants’ experiences. 4.1 Demographic Characteristics of Participants Participants were made up of foreign based players (n=2) and local based players (n=29). Majority of these players (n=19) play for premier division clubs: Kumasi Asante Kotoko, Accra Hearts of Oak, Accra Great Olympics, and Ashanti Gold. Their ages ranged from 19-32, with average ages of 25.5. A number of them were Christians (n=20). In terms of marital status, majority were single (n=28). Moreover, most of them (n=22) had attained secondary education. The following were the positions of the footballers sampled: defense (n=9), midfield (n=10), forwards (n=10) and goalkeepers (n=2). The most reported injury was ankle (n = 12). However, the participants reported other injuries including knee, anterior cruciate ligament (ACL), groin, broken foot, muscle tear, cross boundary, tibia fibula fracture (TFF), and hamstring (see Table 1 below). 26 University of Ghana http://ugspace.ug.edu.gh Table 1 Demographic characteristics of participants (N=31) Variables Frequency Percent (%) Religious Affiliation  Christian 20 64  Islam 11 36 Marital Status  Married 3 10  Single 28 90 Educational Status  Basic 7 23  Secondary 22 71  Tertiary 2 6 Ghanaian Players  Foreign based 2 6.5  Local based 29 93.5 Division  Premier 19 61.2  First 6 19.4  Second 6 19.4 Positions  Defense 9 29  Forward 10 32.3  Midfield 10 32.3  Goal keeper 2 6.4 Type of Injury  Knee 5 16  Groin 4 13  Hamstring 1 3  Tibia and Fibula Fracture (TFF) 1 3  Cross boundary 1 3  Ankle 12 39  Anterior Cruciate Ligament (ACL) 4 13  Broken Foot 2 7  Muscle Tear 1 3 4.2 Findings Four (4) superordinate themes were extracted from the data: mode of sustaining injury, response following injury, mode of treatment, and coping strategies. Mode of sustaining injury had two subordinate themes: body contact (subthemes: accidental body contact, game aggression, and obstruction) and non-contact (subthemes: accidental, and improper 27 University of Ghana http://ugspace.ug.edu.gh landing). Furthermore, response following injury had two subthemes: emotional distress and psychological effect (subthemes: negative emotions, and positive emotions). The mode of treatment also had three subthemes under it: medical (orthodox) (subthemes: hospital treatment, camaraderie, and self-medication), herbal treatment and mixed method (orthodox together with herbal treatment) (Table 2). Also, coping strategies had three subordinate themes: spiritual coping (prayer), social support (subtheme: support from friends, and support from family), and normalizing of injury. These themes are presented in the table below (see Table 2): 28 University of Ghana http://ugspace.ug.edu.gh Table 2 Superordinate and subordinate themes (N=31) Superordinate theme Subordinate theme N Mode of sustaining injury Body contact: 18 Accidental body contact Game aggression Obstruction Non-contact: Accidental Improper landing Emotions following injury: Emotional distress Psychological effect: 24 Negative emotions (Feeling bad, Sadness and anxiety, and Feeling sad) Positive emotions (mental toughness, and better physical quality of life) Mode of treatment: Medical (orthodox): 24 Hospital treatment Camaraderie Self-medication Herbal treatment Mixed method (orthodox together with herbal treatment) Coping strategies: Spiritual coping (prayer) 22 Social support: Social support from friends 24 Social support from family 20 Normalizing of injury 19 4.3 Modes of sustaining injury As a contact sport, some of the injuries sustained by players were the result of body contact. The body contact was sometimes accidental, or obstruction by hitting/sliding another player. Some also involved the use of aggression by stamping the opponent. Participants also indicated that their injuries were sometimes sustained through non-contact means. They were purely accidental, or improper landing. Body contact: The footballers (n=18) revealed that their injury was as a result of body contact. There were instances where they had to go in for 50-50 balls. Fifty-fifty balls are scenarios whereby none of the players have an upper hand in terms of possession. With 29 University of Ghana http://ugspace.ug.edu.gh such scenarios, the one who puts in more effort is likely to possess the ball. In their bid to possess the ball, they often come into body contact with their opponents leading to injury. Such body contacts could either be accidental, aggressive or obstruction.. Accidental body contact: This theme seeks to show how in a playing scenario, an opponent can accidentally fall upon another footballer thereby causing injury to his opponent. Since football is a contact sport, the bodies of footballers contacting each other is inevitable. Such body contacts lead to injuries which were not intended to occur; “So at that time I also decided to use my hand to protect myself but the player next to me also jumped and stepped on my hand preventing me from using my hand to protect myself. I removed my hand so all my body fell and I got the injury to my ankle and hand” (P11, centre back, 24, ankle, Christian) This participant narrates how he sustained his injury at the training ground. The setting conveys the idea that a player would not deliberately harm his colleague from the same team, as such injuries from training sessions are without any malice. He recounts how the slippery nature of their pitch caused him to slip and to lose his balance. In the process of falling, he decided to support himself with his hand but at the same time a colleague who had jumped, landed on his hand and this made it difficult for him to support the whole body with the hand. Apart from the injury he sustained to his hand, he also sustained another to his ankle due to the body contact. Game aggression: The theme shows how in an attempt to possess the ball, footballers apply some level of instrumental aggression. They often apply it without malice, but with the intention of gaining possession. However, there are some that are diabolic. It is in that process that they sometimes knockdown their opponents leading to career threatening 30 University of Ghana http://ugspace.ug.edu.gh injury; “Actually, I was then in South America, in a first division club. A ball was floated in the 18 box. I was going to shoot to score and a defender came and stamped my knee resulting in the injury…So that is where I got injured” (P7, Midfielder, 21, knee, Christian) This quote depicts an aggression that is intended to harm an opponent. Unlike other scenarios where defenders tackle in order to dispossess their opponents of the ball, this particular one was with an evil intent. The defender went straight to stamp his knee. There are times one would go in for the ball, and in the process injure his opponent. But this participant paints a picture of a defender whose intent was to cause harm. On the other hand, the 18-yard box is a critical area of the pitch where the opponent could easily score and this demands swift reactions to prevent the opponent from scoring. Such a scenario could have also accounted for why the defender went straight to stamp his knee. “When I was with [name of club] and we were playing with [name of club], I got a 50/50 chance but I was attacked by the striker who stamped my knee getting me injured in the process. So it was a contact with the striker that got me injured. After the match, when I came back I realized I couldn’t train hard again” (P26, centre back, 24, groin, Christian) Whereas the 7th participant sustained the injury through a stamp from a defender within the 18-yard box, this player sustained his from a striker. The 50-50 chance captures a scenario where none of the players actually was in possession of the ball, or had an upper hand. The more aggressive of the two could gain possession of the ball. In an attempt to gain possession of the ball, the striker stamped him, leading to his injury. Though he sustained his injury through a stamp just like that of the 7th participant, his could not be deemed 31 University of Ghana http://ugspace.ug.edu.gh diabolic because of the circumstances surrounding the tackle. Moreover, strikers are not accustomed to such tackles. This could be a classical scenario of the use of instrumental aggression. Howbeit, its use resulted in this player sustaining an injury. “We were playing a match, and then I was about to score then I had a direct blow from the goalkeeper. He used his leg to stamp my Tibia and Fibula bone and they got broken. So it was a direct blow from the goalkeeper” (P8, striker, 28, tibia fibula fracture, Christian) Again, the 18-yard box (penalty box) is where one will encounter a lot of tussles. This scenario depicts a situation where he was at the verge of scoring but had to be impeded by the goalkeeper. In this case it appears the goalkeeper was the “last defender” to stop him from scoring. The “blow”, which entailed stamping his tibia and fibula bone was an aggressive act which could be deemed diabolic. The tibia and fibula bones are the two bones of the lower limbs. For the “blow” to break these two bones, one could suggest that it was not only intended to prevent him from scoring, but to also cause harm. Obstruction: On the field of play, the task of the defender is often to impede the movement of the striker by way of preventing him from scoring. The area on the pitch where a player finds himself is of essence. Defenders are called to duty within the 18-yard box to obstruct the striker since he could easily score from that spot. In the process of preventing the striker from scoring, defenders sometimes give hard tackles that cause injuries; “First of all, the ankle injury was due to a tackle I sustained from a defender. A sliding tackle it was. It came in the second half of the opponent’s penalty box. I was with the ball, as I was moving with the ball, I got that sliding tackle back behind me, so when I stood up I couldn’t feel my ankle, from that moment I couldn’t even move so I went off the game. Within a 32 University of Ghana http://ugspace.ug.edu.gh couple of minutes, I saw the ankle swollen and that was all” (P28, left back, 32, ankle, Christian) The striker’s position at the second half of the penalty box of his opponent demonstrates that he was almost about scoring when he received a tackle from behind. This often happens in football when the defenders have to use that as a last resort since he is the last man who could prevent the striker from scoring. Though from behind, the sliding tackle was aimed at obstructing him from scoring. If the defender had not done it, chances were that he could have scored. But in the process of obstructing him from scoring using a sliding tackle, the defender caused him to sustain the injury to his ankle. “Yeah we were playing a friendly match against [name of team] at Cape Coast and I got a chance to score as a striker. So the defender hit me behind my right side in my ankle. Since then almost 2 to 3 months I’ve not been playing” (P15, striker, 19, ankle, Christian) In the same way, this participant also got a ball and was almost about scoring when the defender tackled him from behind. The hit from behind was intended to obstruct him from scoring. This is a common tackle defenders use in stopping strikers from scoring. From behind, they often knock the ankle of the striker against the other to cause him to fall down thereby preventing him from scoring. In this case, the hit from behind caused him to sustain the injury, keeping him away for over three (3) months. Non-contact: Whilst some injuries are the consequence of direct body contacts (i.e., whether deliberate or accidental), others are the result of non-body contacts. They happen purely by accident. There are footballers who just by the act of running, discover that they are injured. In such cases, one cannot blame a human agent to be the cause of the injury sustained. The non-contact injuries take the form of accidents, improper landing, and nature 33 University of Ghana http://ugspace.ug.edu.gh of the pitch. Accidental: This theme describes how footballers sustain injuries on the field of play while running. As they run, they engage the activity of the muscles which sometimes gets damaged. When it happens this way, the player does not necessarily need to be knocked down before he sustains such an injury. Apart from damage to the muscles, other parts of the body sustain injuries without any form of external contact; “We were playing the match and suddenly I started having some sharp pains in my thighs so I had to inform the coach and I was taken off the game.. I did not know that was a serious injury but it was so bad that it took me off the field for about 2 years and up till now I am still feeling the pain” (P12, midfielder, 27, groin, Christian) According to this participant, on the field of play he began to experience pains in his thighs without any form of external contact. He only informed his coach about it but did not really know the gravity of it until later on when it kept him away from the field of play for two years. At the time of the interview, he disclosed that he was still feeling the pains. He took those sharp pains for granted, and later paid dearly for it. It appears muscle injuries are taken lightly by footballers, but are very devastating. “Yeah. It was during a game that I got the injury, I was just running and then I fell. After going for an MRI, the doctor told me I had an anterior cruciate ligament [ACL] tear. That is, one of my vein is cut so they have to do a surgery and repair it for me so we went through that process. They did it, and I had to stay at home for almost a year” (P21, goalkeeper, 28, ACL, Christian) In a similar vein, this participant took it lightly. He, saying that “I was just running and 34 University of Ghana http://ugspace.ug.edu.gh then I fell” depicts a normal routine where he never expected that he could sustain an injury. Until the MRI was conducted, he was not aware that he had sustained an injury that was serious. In fact, the injury even demanded that he be operated upon. He ended up spending a year at home because of the tear of his anterior cruciate ligament (ACL). “Okay!!! I had a call out to the national under 20. So I think during training session, I had the ball and had to turn and kick a shot. So while turning on my right leg in order to kick with the left one, I felt some pain in my foot. So I couldn’t continue with the training, demanding that I show it to our doctors who took me to the hospital for an x-ray. So it was after the x-ray that I realised that the bone was broken” (P14, striker, 22, broken foot, Christian) Aside muscle injuries sustained on the field of play without any form of body contact, there are other forms of injuries sustained in a similar manner such as injuries to the foot. Though broken bones are normally sustained through body contacts and aggression, this participant’s foot was broken when he tried turning around to kick a shot. This shows that his injury was sustained purely by accident. Moreover, the setting reveals that it was during a training session, without any contact whatsoever. Improper landing: This theme shows how footballers sustain injuries when they fail to land well. The game demands some occasional jumping. When players jump and do not land well, sometimes they sustain injuries to their ankle, knee, or muscles; “Well, as I said I was playing in Qatar. I was in Qatar when I had this injury. It was during a training session like this, and then, I couldn't land very well on my right leg so I had it twisted. My knee twisted, and after a thorough check, MRI and everything, they told me I had an anterior cruciate 35 University of Ghana http://ugspace.ug.edu.gh ligament [ACL] tear. So a total tear of my ACL need a reconstruction. So that was how it happened” (P3, midfielder, 32, knee, Muslim) This participant recounts how during a normal training session he sustained an injury to his knee. This was sustained without any external body contact. He jumped and failed to land well, and as a result his knee got twisted consequently leading to the tear of his anterior cruciate ligament (ACL). The torn ACL required a reconstruction, where an extra muscle was added in the process. Elsewhere, he indicates how such a reconstruction had become a blessing since he was now fit than before. 4.4 Emotions following injury Following injury, participants described how they felt. They normally felt some physiological effects in the form of pains immediately after the injury, and afterwards experienced some psychological emotions. The psychological emotions were experienced in the form of sadness and depression. Others also felt bad after sustaining the injury; Emotional distress: The first effect of the injury sustained by footballers is physiological in nature. They revealed that they often feel pains within the region of the injury sustained; “Yeah on the pitch I felt pains in my veins immediately I got injured. I didn’t feel happy because the pains was pulling me a lot. Even now it continues to pull me” (P12, midfielder, 27, groin, Christian) This participant reveals how he felt, and still feels some pain after sustaining the injury. He is forced to play even in pain since there is a lot of competition for his position. Psychological effect: There were also psychological emotions experienced by footballers (n=24) after sustaining the injury. The psychological responses took the form of both negative and positive responses. The negative responses were generally expressed through feelings of sadness, sadness and anxiety depression, with some indicating how bad they 36 University of Ghana http://ugspace.ug.edu.gh felt after the injury. Negative emotions (feeling bad, sadness and anxiety, and feeling sad): This theme explains how participants experienced negative emotions as a result of the injuries they sustain on the field of play. The negative emotions were expressed in feeling bad, sad, and sad and anxious as well as being depressed. They felt sad because as players they needed to play more matches, in order to improve upon their performance. If you do not improve upon your performance that will mean losing your position to another player. Losing your position to another player will consequently affect your finances since you would not get winning bonuses. They become very sad when they get to know that they would not be able to play for some time. The thought of that scares them, thereby producing feelings of sadness. They also feel bad that they would lose their agility when they continually sit on the bench without practicing. Thus, losing match fitness; “I was feeling bad because sometimes I had to go to the training ground and sit down and watch my colleagues playing. You know I don’t feel happy” (P12, Midfielder, 27, groin, Christian) This participant felt bad whenever he went to the training grounds to watch his colleagues play. The thought of losing one’s position to a competitor, compounded this player’s plight. Other players have already indicated that there is fierce competition for positions in clubs. So being injured means that his competitors got the chance to justify themselves. If they are not able to justify their inclusion, then it will be difficult to gain back their positions. Brooding over this makes him feel bad. Others feel bad because of the thought that it takes time for one to recover from injury. The thought of being side-lined due to injury makes them feel bad; “I felt bad because the Doctors told me footballers who sustain these kind 37 University of Ghana http://ugspace.ug.edu.gh of injury hardly return to the field of play. So I felt bad because I thought that will be the end of my career. I was told players like Michael Essien sustained similar injuries and were not seen again. So I felt very bad” (P21, goalkeeper, 28, ACL, Christian) The knowledge this participant gathered about other footballers who had suffered similar injuries, and the fact that they were unable to return to the field of play made him feel bad. If the likes of Michael Essien had their football career truncated due to a similar injury, then inevitably he would also suffer a similar fate. Feeling bad was a product of the fear that he is likely never to grace the football pitch again for the rest of his life. “So I was very sad and anxious because I was among the 18-man squad and there is a special package you will be given, plus your bonus. With the injury I could not play, I had to be at home. So I missed all the bonuses, which is very disappointing. I was very sad Football is what I survive on” (P5, striker, 24, ankle, Christian) This participant has not learnt any trade aside from football, and as such football is his only means of livelihood. In the above quote, he felt sad due to the injury he sustained. Being in the 18-man squad meant that he will have the opportunity of not only playing, but also receive winning bonuses and other special packages. The thought of losing all the special packages associated with being part of the 18-man squad brought him feelings of sadness. He had to be home for the entire duration of his injury. Anxiety had to set in since he did not know when exactly he would come back to the field of play. Coming back to the field meant that all the special packages, and winning bonuses would be restored to him. “I felt sad once in a while, because sometimes you wish people can do more to help you in your situation, but people don't really care like that. They 38 University of Ghana http://ugspace.ug.edu.gh also have their own problems and they are more focused, they don't really care about you, you know. Especially people you've really helped, people you think, no, I think you have to be there for me will all disappoint you and it is very frustrating and painful” (P8, striker, 28, tibia fibula fracture, Christian) Here this participant’s sadness was not only attributed to the injury, but for the fact that those who were supposed to be there for him throughout the period of injury were nowhere to be found. They had to also focus on their own problems. There were people he had helped in time past who had turned their backs on him at a time he needed them most. To him they had disappointed him, resulting in him feeling sad. However, there are other footballers whose feeling of sadness does not emanate from financial loss nor desertion by people they have once helped. Their sadness comes from their inability to play the game they love; “So anytime I see my colleagues enjoying the game and me I am out, I feel very sad... I was not happy at all. Sometimes even when we start the pre- season, I sometimes force myself to run on my leg. But within 15 to 20 minutes I stop but my colleagues will finish full training” (P15, striker, 19, ankle, Christian) This participant expressed the worry that his state of injury had forced him to sit on the bench even during training sessions. His sadness comes from the fact that his colleagues are “enjoying the game” whilst he is seated on the bench. Enjoying the game shows that they do not play the game for financial rewards but for the love of it. There were occasions where he had to force himself to play whilst injured just for the joy derived from playing the game. The thought of his colleagues enjoying themselves on the field of play whilst he 39 University of Ghana http://ugspace.ug.edu.gh sits on the bench made him sad. Sadness could also come from other sources such as the feeling that the team would be affected due to their absence; “Hmmmm!! Normally when you are a key player in a team and you get injured, it feels very bad because it will affect the team. Though we have players on the bench my role as a key player is very crucial so when the injury occurred I for that one, got bored, I got sad” (P16, midfielder, 32, ankle, Muslim) The participant saw himself as an integral member of the team. As such his absence from the team due to injury would affect the team. His feeling of sadness was not about himself, but the loss to the team. Whereas other players feel sad because someone might take over their position, costing them both playing time and winning bonuses, he did not see his position to be threatened in any way because he is a key player in the team. He became sad because a key player like him will be missed by the team, which could affect their performance. “So they took me to the hospital and I went in for an x-ray. After the x-ray that I saw that my leg was broken. Yeah!!! So I was very depressed and it took me out of the game for some time. I think 8 months or so before getting back to the pitch. I was very depressed. It will get to a time you will even feel that challey!!!! This injury will not go” (P14, striker, 22, broken foot, Christian) According to this participant, it was not until the x-ray report showed that he had a broken foot that he became in his own words depressed. He became depressed due to the length of time it took him to return to the field of play. Like other players who felt sad they were 40 University of Ghana http://ugspace.ug.edu.gh likely not to come back to play football again, the same thought caused this participant to be depressed. Positive emotions (mental toughness, and better physical quality of life): Participants also expressed positive emotions as to how the injury had become a blessing to them. They showed how it had made some of them mentally tough, and improved their physical quality of life; “Then it also made me strong in a way. It opened an avenue where I knew that I was strong within. I didn't know I was strong like that, and knowing who real friends are in your adversities, you know. Those people you least expected they were true friends that's where you see true friendship. And then it also gave me an opportunity to push more, speak to myself that I can do it. The doctor has given me a year but I can beat that year, which I was able to do. So my mentality have become stronger than before. I’m used to more of myself and I don't look up to people. I challenge myself to do more to prove people wrong” (P8, striker, 28, tibia fibula fracture, Christian) Though this participant laments how the injury had robbed him of so many opportunities, nevertheless he has learnt a lot from the injury. He shows how it has made him strong in a sense. Hitherto, he never knew how strong he was, until he sustained the injury. His injury challenged him, and taught him to prove people wrong. The injury has also revealed who his true friends are. To him, true friends are those who are there for you in times of adversity. He enrolled in one of the universities in Ghana during the period of injury, and is about completing the programme. He has made up his mind to use his life to challenge others that they can always bounce back after injury and even become better. It is the mental toughness that has helped him in his teaching assistantship and playing career at the 41 University of Ghana http://ugspace.ug.edu.gh same time. The injury was a blessing in disguise. Well, as I said, it was ligament tear. There has been a reconstruction and now I'm fine, I'm playing like never before, okay. I’m playing as though nothing has ever happened” (P3, midfielder, 32, knee (ACL), Muslim) In a similar vein, this participant saw the injury as a blessing in disguise. Though he had to go for surgery due to the nature of the injury (which was an ACL tear), its success has made him far better than he was before the injury. He attributes this to the fact that he got professional treatment from Qatar where he is plying his trade as a professional footballer. Had it been in Ghana, he doubts he would have received proper treatment. But being in Qatar afforded him the opportunity to receive proper treatment. The fact that some footballers have had similar surgeries and have not been able to return to the field of play gives him reason to be grateful. 4.5 Mode of treatment There are a number of treatment options available to footballers in Ghana. Some resort to either orthodox, herbal, or mixed treatment of both orthodox and herbal medicine. Reasons why they may subscribe to any mode is underpinned by the policy of the club they play for and/ or their belief about the efficacy of the type of treatment. Medical (orthodox): This theme describes how players (n=24) receive hospital treatment through arrangements made by their clubs. Others received medical help or advice from their colleagues. The players also indicated belief in self-medication. Hospital treatment: When it comes to orthodox medicine, the club sometimes makes arrangements for the players to go for check-ups and treatment either in a government facility or one provided by the club. Clubs in high financial standing have their own health facility where players are treated. For others, agreement has been reached to refer their 42 University of Ghana http://ugspace.ug.edu.gh players to some health facilities. However, players from less endowed clubs especially at the second division level have to find a way of treating themselves with little or without any medical support; “Yeah. That’s why I said, I went for an x-ray and the doctor checked and prescribed some medicine for me, so I took the medicine. First, like, if I run a bit then my knee will be swollen but now it has come down. Because, first if I play small, then I hit the ground small then my knee starts swelling. But now if I play it doesn’t swell like before, it doesn’t do like first” (P2, defender, 24, knee, Christian) This participant plays for one of the big clubs in Ghana. He was asked by the club to go for an x-ray to reveal the extent of injury. He does not believe in herbal medicine because herbalists lack the ability to rightly diagnose the injury. He did not want to take chances hence the decision to go to the hospital as instructed by the club, and complying with the prescriptions of the doctor. Moreover, the club does not encourage the players to go for herbal treatment. “Ohhh!!!! They help me a lot because they take me to special hospitals like 37 military hospital for x-ray to check if it has affected the bones. After that they took me to Valley View. It’s a private hospital. So they gave me some quality drugs that’s why now I am fit. The team helped me a lot because it is in my contract if I get injury or sick, they will take care of me. So they helped me a lot” (P15, striker, 19, ankle, Christian) This participant’s club also took him to the hospital as it is the club’s policy to give their players proper medical treatment. It is also enshrined in their contract with the players to provide them with medical care. The player is not expected to seek for treatment elsewhere 43 University of Ghana http://ugspace.ug.edu.gh on his own accord. Therefore, it was the responsibility of the club to take him to the hospital when he got injured. The club does not believe in herbal medicine because its management is partly European. There is also a team doctor who attends to them before referring cases to the specialist hospital. He indicates that he was given quality drugs which helped him in the recovery process. Further, he suggests that his club really lived up to expectation as dictated by the contract he signed with the club. “I came to this team with the injury, I had this injury in the previous team. I came here with the injury so when I came, the physio took me to a specialist for an MRI scan and they saw that it was a partial tear of the ACL so when I came back, the team has been taking care of me as in the treatment from the hospital. So that is basically what they have been doing” (P24, Midfielder, 23, ACL, Christian) Also, well established clubs like the one this midfielder plays for recommend medical/orthodox form of treatment for players with injuries. The club signed him on in his state of injury. Considering the financial commitment in treating footballers, signing on a player who is injured speaks volume of the ability of this player. The team considers him as a great asset worth investing in by way of medical support. In this club, they do not entertain herbal medicine partly because these injuries must first of all be ascertained through scanning, which is lacking at traditional treatment centres. The club has its own physiotherapist as do other premier league clubs. Camaraderie: This theme seeks to explain the kind of treatment offered by other teammates. They usually prescribed for their injured teammates their own local knowledge for orthodox treatment. Sometimes these colleagues help in the treatment process by offering themselves as physiotherapist to massage them. The reason for relying on 44 University of Ghana http://ugspace.ug.edu.gh colleagues are basically financial, since most of them cannot afford professional treatment; “It’s both because here in Ghana I don’t think we have enough facilities for that medical treatment. Maybe other places or the advanced clubs, the first division and the premier league. Maybe they will have physios and other team doctors who are qualified. But second division sometimes, it’s your own colleagues. Me for instance it was one of my colleagues who was doing it for me. He will massage it for me every morning. Sometimes he will buy some painkillers for me so that the pain will calm down”(P20, midfielder, 25, ankle, Muslim) This participant attributes the reason for relying on colleagues for orthodox treatment to the lack of medical facilities. He further confirms the fact that it is only the bigger clubs with strong financial standing who are able to provide their players with professional medical support. The only thing the club could afford is money to buy pain killers. Moreover, he had to rely on colleagues to provide some form of physiotherapy by massaging his leg for him every morning. Self-medication: The players personally see to their health by providing self-medication. They believe that apart from the massage and other treatment they receive, they also owe it a duty to play their part in the recovery process by buying some medicine to take care of themselves. There are times their colleagues will offer to buy them the medicine for them to use; “As I told you earlier, we believe in self-medication. Maybe I took Voltaren which is okay for me. I might recommend to someone who is having the same problem but he doesn’t know it is that deep. He will go and take Voltaren, he feels okay, he will come and play today, tomorrow, and then 45 University of Ghana http://ugspace.ug.edu.gh he has a swollen knee again. Somebody also recommend Naprosyn EC, somebody also recommend a whole lot. But then after taking all these first class antibiotics or painkillers and if he doesn’t feel okay for some time, you see that he gives up and then start to look for something else to do. So most of them are giving up on football and then they have taken another measure to survival” (P2, defender, 24, knee, Christian) This participant makes a strong statement to the effect that footballers believe in self- medication. They recommend different kinds of medicine to their colleagues based on trial and error. By experience, they know which kind of medicine is good for treating certain injuries, so when a colleague complains of suffering a particular injury, those who have ever suffered a similar fate recommend medicines they used which proved helpful. He reveals that due to self-medication, some have ended their careers not receiving the right kind of treatment. When this happens, they abandon the whole idea of football and find another trade to make ends meet. Herbal treatment: When footballers suffer some form of injury, they sometimes go for herbal treatment. They do so for two reasons: belief in the efficacy of herbal treatment, and recommendation from their team to go for such treatment; “When the injury came I didn’t know what to do. Because the way it was, I didn’t take it to the hospital. So our team they brought a traditional herbalist who was treating the players. So he just did some treatment for me…” (P17, midfielder, 21, ankle, Christian) This participant reveals that it was his club which made arrangements for a herbalist to come over to treat players who were injured. Financial constraints normally forced some clubs (especially second division clubs) to seek the services of a herbalist. Moreover, this 46 University of Ghana http://ugspace.ug.edu.gh participant thought that herbalists were very good at treating blood clots and fractures. Comparatively, herbal medicine heals faster than orthodox medicine. Apart from the fact that herbal medicine heals faster compared to orthodox medicine, it is also cheaper; “That time I decided to use orthodox medicine, but I didn’t have any support. Who will pay the money? There is no one to lean on. So at that time I was the one taking care of myself. So I will just talk to some of my friends to find out if they know someone who is good on how to treat a player with herbs then I just go to the person” (P11, centre back, 24, ankle, Christian) According to this participant, another reason why they go in for herbal medicine is because they do not have the financial support to patronise orthodox medicine. This player plays for a second division club, which for their poor financial standing are unable to give their players orthodox treatment when they get injured. He indicates that he had to rely on herbal medicine because he had no option since there was no financial support to go for orthodox treatment. Not only does he go for herbal medicine, but also he recommends herbal medicine to his colleagues who find themselves in similar situations. Mixed method (orthodox together with herbal treatment): There are footballers who also use a mixed method of both herbal and orthodox medicine. After going for orthodox medicine, they still go in for herbal treatment to complement the orthodox medicine. From hospital they have their own herbalist they visit for additional help. Through experience, they have realised that the herbal medicine heals faster compared to the orthodox medicine; “Yeah, I started treatment with the medicine but it takes time. The medicine will take time, but for herbal medicine it takes like a week or two for you to feel much better. But the orthodox medicine takes time. It takes time. The way the doctor said gradually, gradually, but the herbal will clear 47 University of Ghana http://ugspace.ug.edu.gh everything like in two weeks or in one week” (P1, defender, 30, ACL, Christian) This participant is a former Black Stars player plying his trade outside Ghana. He got injured whilst playing for his club abroad. Over there, he was given orthodox treatment, but discussed it with his coach to come down for herbal treatment. This is because from experience he realised that orthodox medicine takes a longer time to heal compared to herbal treatment. Though the club puts their players on orthodox treatment, he normally goes for permission to add herbal treatment which has proven helpful. “That injury has kept me home a lot, almost three months. So I went to hospital, because herbal medicine is not easily accessible in the city compared to the village. So, sometimes I ask that they bring me some herbal concoctions from the village…They say if you cook the leaves and drink it in the morning it will help the pains too to go down. I have not been taking the medicine given to me when I went to the hospital. I always take the herbal leaves. I put it in water and drink it” (P5, striker, 24, ankle, Christian) This participant usually patronized herbal medicine whilst in the village, but finds it difficult to access herbal treatment in the city where his current club is located. He reveals how they even send him herbal medicine from the village. Though he went to the hospital and was given drugs, he refused to take them even though it is the arrangement of the club for players to go for orthodox treatment as enshrined in their contract. Like other footballers, this participant is of the view that herbal medicine heals faster than orthodox medicine. To him the mixed method is necessitated by the fact that orthodox treatment is mandated by the club, but he prefers herbal treatment. 48 University of Ghana http://ugspace.ug.edu.gh 4.6 Coping strategies Coping mechanisms help individuals to deal with a challenging situation and this can have a positive impact on quality of life. During the period of injury, footballers develop or resort to some strategies to help them cope with their injuries. They either cope through prayer, social support or normalising the injury. Spiritual coping (prayer): Spiritual coping takes the form of prayers. This is with the understanding that nothing actually happens by chance, as there are spiritual forces at work against them. They (n=22) believe that prayers are able to both cure them of the injury they have sustained, and to fortify them against spiritual attacks and bring them back to the field of play; “Prayers have helped me a lot. At first I didn’t use to pray. I thought everything was normal but I realised after my injury that it is not so. Now I have started praying and it has helped me a lot. My pains have gone down. At first I couldn’t raise it like this but now I can raise it. It has helped me, the praying has helped me a lot” (P25, Offensive midfielder, 21, knee, Christian) The participant reports that he copes using prayer during his injury. This offensive midfielder subscribes to the belief by others that an injury could be as a result of a colleague engaging a spiritual power against him. The statement “I thought everything was normal but now I have started praying” suggests that initially he did not believe that a spiritual force was behind his injury. He further acknowledges that it is the prayers that have been able to ameliorate the injury, testifying of the efficacy of prayer in dealing with the injury situation. Social support: Participants revealed that they received social support from their friends 49 University of Ghana http://ugspace.ug.edu.gh and their family members. Their friends were their colleagues with whom they play with, whereas their family members were those of their nuclear family. These often encouraged them within the period of injury to provide emotional support to help them cope with the injury. Social support from friends: Social support from colleagues/friends also helped some participants (n=24) to cope with their injury. The presence of their colleagues was helpful such that it keeps them from musing over their injury, which will consequently cause them to feel sad, bad, anxious or depressed. Thus, both friends and colleagues alike come around them and show some form of solidarity; “Yeah, they helped me, you know. Because when you are inside alone in a room you will think a lot. But during that time they do call me, eh challey, how is the injury? They crack jokes to make me laugh so that I can forget about a lot of things. So they do entertain me. Sometimes, I have about three or four friends in Accra here. They do come to my house, you know. They entertain me, we will be inside, we will be laughing and be cracking jokes so that brings the tension down” (P4, Forward, 26, ankle, Muslim) His friends basically use an emotional coping mechanism to help him. All the entertainment, laughter, and jokes are helpful in distracting his attention from the thoughts about the injury. He sees loneliness as a contributory factor to his worries and considers the presence of his friends an important factor in attenuating the feeling of loneliness. Social support from family: Some participants (n=20) reported that family members help them cope with their injuries. Sometimes family members physically come around them, and at other times they remember them in their prayers. They come to offer pieces of advice, and offer some level of emotional support; 50 University of Ghana http://ugspace.ug.edu.gh “Well, my mum, my mum and my brother are my family. At least they are the people who are very close to me, very tight. They are the people who give me motivation. My mum was, she was like, things happen for a reason. It has been like that since infancy. She gives us hope. She’s practical, very, very practical, so she gave us hope. So she was like, you know, it happened for a reason, I shouldn't relate it to anyone, as I said earlier. So my family that I know played a major role for me being okay” (P3, Midfielder, 32, ACL tear, Muslim) This footballer discloses the level of intimacy between him, his brother, and mother. He indicates that they are his source of motivation. The encouragement from his mother could be said to be rooted in their Islamic belief in God as the ultimate cause of events and happenings as corroborated by some of the participants (midfielder, 25, ankle, Muslim; Forward, 29, ham string, Christian). Saying “I shouldn’t relate it to anyone, as I said earlier” presupposes that he does not subscribe to the belief that someone engaged a spiritual power to cause his injury as suggested by others. Such encouragement from his mother affirms the power of God to deal with the injury since He permits it for a purpose. Normalising of injury: Generally, footballers (n=19) saw injury to be part of the sport. After sustaining injuries in the course of their careers, some footballers have come to accept the fact that injuries are part of the game. In essence, it is inevitable, demanding that one embraces it as such and not blame it on anybody. This could be inferred from a statement of one of the participants: “No I don’t believe. I don’t believe because when I got the injury people were telling me maybe some of my colleagues did this to me and others but I didn’t believe them because I was just running and nobody pushed me so 51 University of Ghana http://ugspace.ug.edu.gh when they were saying, I didn’t believe. I know is an injury and injury too is part of the game so you can get injured at any time. So I thought it was a normal injury” (P21, Goalkeeper, 28, ACL tear, Christian) The participant rationalizes that the injury is an expected consequence from the profession. He thus found other non-rational views unacceptable. This goalkeeper played in this particular club from his early years. The club in question has its philosophy rooted in the academy style of management thereby imbibing western style of training. Thus, his socialization within the club might have influenced him to take such stance. “Well, as I said earlier, when I got injured because of there were people around me who had the same injury I didn’t see it to be a problem. I saw it to be like a normal headache that you take a painkiller then you’ll be okay. Because I was around people who had the same thing who were playing top flight” (P3, midfielder, 32, knee (ACL), Muslim) The participant is able to cope with his injury because he has seen others who have sustained similar injuries and have been able to come back to the field of play. He does not see it as a problem, but considers it as a normal headache which comes and goes at any time. Knowing that others who play top flight football also sustain such injuries, gives him the hope that it will be well with him. 52 University of Ghana http://ugspace.ug.edu.gh CHAPTER FIVE DISCUSSION, RECOMMENDATIONS AND CONCLUSION 5.0 Introduction This chapter starts with the aims of the study, and a summary of the findings. In subsequent paragraphs, findings are discussed in relation to other studies and the cognitive appraisal model of stress and Africultural coping theory. Also, the chapter gives the implication of the findings, and goes further to state the limitations of the study. Based on the limitations, recommendations for future studies are made. The chapter concludes by showing how the findings confirm existing studies, as well as new findings that were observed in the study. 5.1 Discussion The study aimed at exploring the lived experiences of footballers with career threatening injuries in Ghana. Specific objectives were to explore the psychosocial problems footballers with career threatening injuries in Ghana face, how these problems affect their well-being, resources accessible for rehabilitation, and the kinds of coping strategies they adopt in dealing with those psychosocial problems. The experiences of footballers clustered around four superordinate themes: mode of sustaining injury, emotions following injury, mode of treatment, and coping strategies. Mode of sustaining injury had two subordinate themes: body contact (subthemes: accidental body contact, game aggression, and obstruction), and non-contact (subthemes: accidental, and improper landing) mediums. Besides, emotions following injury had emotional distress, and psychological effect (negative emotions and positive emotions) to be subthemes under it. Medical (orthodox) (subthemes: hospital treatment, camaraderie, and self-medication), herbal treatment, and mixed method (combination of orthodox and herbal treatment) were subthemes under mode of treatment. Also, coping strategies had 53 University of Ghana http://ugspace.ug.edu.gh three subthemes: spiritual coping (prayer), social support (subthemes: social support from friends, and social support from family) and normalizing of injury. Mode of sustaining injury Mauntel et al. (2017) observed that some kinds of injuries (e.g., ankle injuries) were caused by player contact. In the study, it was found that some of the injuries were sustained through accidental body contact. In a playing scenario, a player could get injured if another player accidentally fell on him. However, there are instances where in an aggressive manner, a player stamps his opponent with/without malice to dispossess him of the ball or win a 50- 50 ball. To obstruct and frustrate the attempts of an opponent from scoring, some players often do so by hitting the ankles of their opponents from behind or by a sliding tackle. This is how some of the participants sustained their injuries. Gebert et al. (2018) corroborates this by noting that whereas 53.0% of injuries are caused by body contact, 29.5% of all injuries are as a result of foul play. Being tackled by an opponent, and turning/twisting have been recorded to be the causes of injury severity. In a similar vein, Shalaj et al. (2016) noted that injuries could be an outcome of substantial physiological demands and contact between players. Although injuries through contacts with other players were recorded in studies outside the context of Africa (Gebert et al., 2018; Shalaj et al., 2016; Smpokos et al., 2018), the findings suggest that how footballers sustain injuries is not specific to some contexts, but could be a general phenomenon. The results supports Akodu et al. (2012) who showed that during the 2011 WAFU cup, 82% of the injuries were sustained through contact with other players. Apart from body contact, there were some injuries which were sustained through non- contact mediums. They were sustained purely by accident, and others through improper landing. These accidental injuries could be as a result of direct trauma or repetitive stress 54 University of Ghana http://ugspace.ug.edu.gh (Longo et al., 2010). Match-induced fatigue brings about muscle damage (Pavin et al., 2018). Similarly, some ankle injuries are sustained through non-contact-mechanisms (Farquharson and Greig (2017). Also, poor running performance has been found to be a risk factor for injuries (Del Coso et al., 2018; Ekstrand et al, 2011; Hagglund et al., 2012). Adjei et al. (2015) indicated that there is a high prevalence of ankle sprain, groin and hamstring strain sports injuries among athletes in Kumasi. Contextually, it could be noticed from the study that some of the injuries arising from non-contact-mechanisms were as a result of the bad nature of the football pitches. Unlike the Astroturf used in Europe, most of the pitches in Ghana are in bad shape contributing to some of the injuries. Emotions following injury Emotional distress was one of the emotions that followed their injury. In addition to that, players experienced some negative and positive psychological effects. The negative effects took the form of feeling bad, sad, anxious, and depressed. Stoltenburg et al. (2011) demonstrated that athletes experience both positive and negative emotions when they contemplate the truncation of their career due to injury. Some common emotions recorded are decreases in vigour, depression, fear, and confusion. These negative emotions sometimes emanate from the fact that they will lose competition activity (Akodu et al., 2012). These psychological challenges might be due to the injury history of footballers. Whereas those who sustain injuries for the first time experience more psychological distress, those who suffer multiple injuries are less likely to suffer psychological distress (Johnson, 1996). This could be the result of how they process their injuries mentally (Lazarus & Folkman, 1984). Going by the cognitive appraisal model of stress (Lazarus & Folkman, 1984), if it is the first time of sustaining a career threatening, the footballer might be uncertain as to 55 University of Ghana http://ugspace.ug.edu.gh whether or not he will be able to continue with his career. Such thoughts makes the situation very stressful. However, the one who has been in-and-out of injury is likely to process the situation as one of those he had suffered in the past. Since he had been able to return to the field of play, he retains the hope that with the current injury he will still bounce back thereby making the situation less stressful. Though the dimensions of injury history was not nuanced in the study, the plausible explanation for these emotional responses could be what is being offered. Further, Gulliver et al. (2015) found that severe and recurrent injuries result in psychological effects such as distress, anxiety, and depression. Tracey (2003) corroborates this, showing that anxiety, depression, fear, and confusion are common emotions recorded after an injury. This is as a result of the re-evaluation of their role on the team (Clement & Shannon, 2011). By conducting a cost-benefit analysis, these athletes evaluate the consequences of their injury as well as the coping resources available to them (Lazarus, 1991). This evaluation affects the emotional response and behavioural reactions of footballers (Wiese-Bjornstal et al., 1998). The fear that their position could be taken by a colleague pushes them to sometimes continue playing in the state of injury. As Young et al. (1994) notes, praise, attention, perceived or real risk of being dropped from the team are some of the factors that encourage athletes to take greater risks in competing or playing in the state of injury. Crossman (1977) found that athletes sometimes put undue pressure on themselves to return to the sport prematurely just to keep playing. They do this due to social accolades, fame, and seduction by financial success as they ignore the signs of fatigue (Hale, 2008). With the desire to become elite athletes, they often embrace a sport ethic which encourages risk taking, long hours of training, and pushing through pain in order to succeed (Messner et al., 2000; 56 University of Ghana http://ugspace.ug.edu.gh Richardson et al., 2008). This is explained by “a culture of risk” as proposed by Frey (1991), where athletes normally train or compete injured in order to succeed. This culture legitimizes athletes’ acceptance of risk-taking behaviour as a necessary aspect of participation (Safai, 2003). McGannon et al. (2013) and Roderick et al. (2000) have suggested that some under-recovered athletes continue competing due to personal ambition, professional pride, or fear of being replaced. For an event to be considered stressful, an individual has to do what Walker et al. (2007) term as “cognitive appraisals”. Per Wheeler’s (2007) assertion, male Ghanaian footballers’ fear of losing playing time, distress of not being able to engage in the sport, as well as financial loss are the thought processes that might have led to stress. Lazarus (1991) puts forward that athletes can have primary and secondary cognitive appraisals of their injuries. Primary cognitive appraisal entails a type of cost-benefit-analysis to evaluate the likely outcome of the injury, whereas the secondary appraises the coping resources and strategies the athlete has to deal with the consequences of the injury. Lazarus (1991) and Wiese-Bjornstal et al. (1998) proposed that both the primary and secondary appraisals are expected to impact the perceived stress of the injury, the emotional response to it, and the consequent behavioural reactions of the athlete. Though Tracey (2003) and Leddy et al. (1994) acknowledge that there are negative emotional experiences (e.g., loss, anxiety, and frustration) associated with injury, there are also some positive experiences athletes acknowledge after sustaining injury. The study confirms this by showing that participants experienced some positive emotions such as mental toughness and better physical quality of life. They explained that their injury made them to realise how strong they were within, and made them physically better than they were. 57 University of Ghana http://ugspace.ug.edu.gh Mode of treatment This theme helped to answer the research question “What resources are accessible for rehabilitation?” To treat the injuries sustained, footballers often received either medical (orthodox), herbal, or mixed method (combination of both herbal and medical) treatments. Those who played for bigger clubs in the premier league or first division had the opportunity of receiving medical treatment from a health facility and the team’s doctor. However, those in the lower divisions had to rely on self-medication and help from colleagues who had some experience in using certain drugs. Since some could not afford orthodox treatment, they had to fall on herbal treatment because it is relatively cheaper and takes less time to heal. Though some got the opportunity to access hospital treatment, they also saw the need to add herbal treatment, with the belief that it heals faster. Moreover, footballers’ decision to go for traditional herbal treatment might be linked to their African believe that there is an interconnection between man and his environment (Nobles, 1986; Post & Weddington, 1997). Thus, the use of herbs could be a way of harmonising with nature or their environment, stemming from an African-centred approach to life (Asante, 1998; Azibo, 1992). Coping strategies Religion has been established as a means of social support (Frey & Stutzer, 2002), with church-based relationships advancing an individual’s sense of belonging which impacts his or her health (both mentally and physically). Religion in this sense could be tied to spirituality since Christians and Muslims believe in God or the transcendent. Williams and Galliher (2006) noted that high levels of social support within the athletic team environment protects some class of athletes from depression. The study demonstrated that participants (irrespective of their religious affiliation) resorted to spiritual coping 58 University of Ghana http://ugspace.ug.edu.gh mechanisms by way of prayer to deal with the psychological and physical effects of their injury. They believed that their personal prayer, and prayer from family members and pastors or Imams could help facilitate the healing process and help deal with the spiritual forces behind their injuries. The thought that prayers would help deal with their problems gave them some comfort and hope of recovery. Although footballers identified with different religious faiths (Christianity, and Islam), nevertheless they converge on the idea that prayer plays an important role in rehabilitation. The overlap in the belief in the transcendent, and His role in the affairs of men could be derived from their religious beliefs, and their African philosophical world view (Asante, 1998; Azibo, 1992). This view encapsulates the active role of the physical and metaphysical forces in the life of an individual. As such metaphysical forces could be engaged to help deal with physical challenges. Also, Gouttebarge et al. (2015) showed that low social support was related to mental health problems. Bianco (2001) and Tracey (2003) found that social support is instrumental in reducing stress, and also maintaining athletes’ motivation during the period of recovery. Athletes rely on both emotional and informational social support to help cope with injury (Yang et al., 2010). In sports, athletes have friends, family, team mates, and coaches to be their social support (Anderson & Williams, 1988). Fletcher and Sakar (2012) for instance showed that athletes are able to cope better when they perceive that there is high quality social support from family and team mates available to them. This is in consonance with the findings of the study. The study found out that, social support from friends and family was able to provide them with the emotional support and encouragement needed to cope with their injury. Post and Weddington (1997) within the framework of collective consciousness upholds the group as a natural support base in terms of coping. For Africans 59 University of Ghana http://ugspace.ug.edu.gh to cope, there is the need to harmonize with events that encompass spiritual manifestations within the material world. Some of the ways by which people of African descent cope with life’s stresses are spiritual-centred coping, and collective coping (Utsey et al., 2000). The former describes how prayer is used as a way of coping, with the understanding that God is involved in the affairs of this life. Moreover, the latter explains how the group can help one to cope. Furthermore, normalizing of injury was also found to be a way footballers tried to cope with injury. They did this by telling themselves that the injury was part of the game and thus inevitable. This way of appraising the situation made it less stressful to them. Johnson (2000), Pargman (1999) have indicated that athletes tend to rationalise and accept injury as a part of sport participation, and an occupational hazard (Young et al., 1994). 5.2 Implications of findings The study revealed that there was lack of psychological attention or intervention to the problems footballers with career threatening injuries face. Attention seems to be skewed towards physical or medical remedies. Though attention is focused on medical remedies or physiotherapy, only a few of the players who play for top clubs in the premier league or first division get this kind of treatment. Recommendations The Ghana Football Association should therefore institute measures that will ensure that players in all clubs receive proper medical care. Clubs should be required to keep proper medical records on their players. Such records should be submitted whenever the clubs want to renew their licence. Regulatory bodies should ensure that clubs with proper or standard pitches are given license to operate since some of the injuries players sustain are as a result of the poor nature of the pitches. Routine checks should be conducted to ascertain 60 University of Ghana http://ugspace.ug.edu.gh the appropriateness of football pitches before licences are renewed. Moreover, there is the need for clubs to hire the services of psychologist and counsellors to help footballers in those clubs to receive psychological treatment for the psychological challenges they face. This should be a prerequisite for registration and renewal of the licences of football clubs in Ghana. The study showed that this was lacking, making it imperative for the clubs to hire the services of psychologist and counsellors. The Ghana Football Association must also institute measures that will ensure that clubs make these arrangements for their players before they could be licenced. 5.3 Limitations of the study Players resident within the Greater Accra and Ashanti regions were used in the study. Though the findings could be transferred to players living within these regions, it makes generalization of the findings to footballers in other regions of the country and beyond quite difficult. Future studies should endeavour to broaden the scope by covering other parts of the country and beyond. Moreover, the study concentrated on the psychosocial lived experiences of footballers as it relates to their injuries, but not with the structural issues (e.g., management) and how it affects their well-being. Future studies could examine or explore the impact of structural factors on players during the period of injury and their lives in general, and how such factors influence their psychosocial well-being. Also, the study explored the lived experiences of footballers with career threatening injuries in general. It therefore failed to give some nuances with regards to what players with specific types of injuries encounter during the process or period of injury. Other studies can specifically look at the lived experiences of a particular type of injury (e.g., only players with ACL injuries). Case studies could be used in that regard for in-depth 61 University of Ghana http://ugspace.ug.edu.gh understanding of their experiences when it comes to specific injuries in football. Besides, the history of injuries among footballers could be explored for depth of analysis, as this study did not examine how the history of injury affected their psychosocial wellbeing. 5.4 Conclusion The study has shown that the nature of a football pitch can contribute to injury. It has also corroborated other findings that have shown that injuries in football are sustained through body contact and non-contact mediums. Further, the study established that emotional distress and psychological effects resembling symptoms of sadness, anxiety and depression are some of the emotional responses of footballers when they sustain injuries. This has also been found in previous studies. Besides, it has also demonstrated that Ghanaian footballers like footballers elsewhere go for orthodox treatment when injured. However, the study has gone ahead to show that Ghanaian footballers also use herbal treatment alone, or in combination with orthodox treatment. Also, the coping strategies used by footballers in other parts of the world are similar to the ones Ghanaian footballers rely upon (social support from friends and family members). Additionally, the study found that Ghanaian footballers rely on spiritual coping strategies (prayer) for coping with injury. Normalizing of injury, as observed in other studies was also found to be a way Ghanaian footballers cope with career threatening injury. Though footballers face some psychological challenges as identified in the study, they did mention the kind of psychological help they receive to help them deal with such challenges. It is evident from the study that such psychological or counselling services are non-existent. 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Demographic characteristics Sex: Male Female Age: Marital Status: Married Single Divorced Separated What is your highest level of educational: Primary J.H.S S.H.S Tertiary Religious affiliation: Christianity Islam Traditional Others Do you have dependents?: Yes No If yes, how many of them do you have?: Which division/national team in Ghana do you play for?: What position do you play?: Type of injury: Questions B1. How long have you been playing football? B.2 Can you kindly tell me how you found yourself in this current state? B.3 Tell me how did you feel when you were first told that you can’t play in the next match because of your injury? B.4 Do you believe there is superstition in football? Probe: To what extent do you think superstition plays a role? B.5 What would you say are the main challenges you have faced during this period of injury? Probe: if he/she mentions more than one challenges find out how he/she ranks them from the most serious to the less serious C.1 Can you tell me about your health? Probe: tell me how this injury affected your health C.2 How has this injury affected your life? Probe: How did the injury affect your thoughts, emotions, behaviour? C.3 What will you say are the main challenges you face as a result of this injury? C.4 How do/did you survive when you are/were not playing as a result of injury? 76 University of Ghana http://ugspace.ug.edu.gh Probe: tell me more about any form of trauma you have suffered? C.5 Tell me how you feel now C.6 Do you sometimes feel sad, angry, nervous, suicidal etc.? Probe: ask for specific emotions and for each one probe with the following questions:  How often do you have this feelings?  What do you consider as causes for this feeling?  How do you come out of such feelings? C.7 Tell me how your injury sometimes make you feel in relations to your team mates, for instance about whether you may lose your position. D.1 Tell me what has been done for you in this situation? Probe: tell me what your club has done to help you in this situation D1.1. What have you been doing to help yourself in this situation? Probe: What do you do to keep healthy: Physically, mentally, emotionally, and spiritually? D.2 Tell me about what the other players do for themselves when they are injured Probe: What do they do to keep themselves healthy: Physically, mentally, emotionally and spiritually? D.3 Tell me: what does it mean to you to say someone is healthy Probe: tell me how this view you hold about being healthy is similar or different from your colleague footballers D.3.1 Tell me the role your club plays in keeping you footballers healthy especially during your period of injury or playing career. D.4 How did you get treatment for your injury? Probe: From where? Hospitals? Pharmacy Shops? Other sources? D.5 Have you ever resorted to herbal treatment for your injury and why? E.1 Can you tell me about some of the coping strategies that you have adopted so far to manage yourself? E2. Tell me about the help you have received since your injury Probe:  How is your family helping you in your current state? 77 University of Ghana http://ugspace.ug.edu.gh  How are your friends, colleague footballers, helping you in this situation  How is your religious organisation (e.g., church/fellow Muslims etc) helping you in this situation? E.3 Tell me more about how your religious beliefs have helped you to cope with this situation E.4 Kindly tell me about some coping strategies other footballers adopt in such situations Probe: Can you tell me about what or who helps them to cope with their injuries? 78 University of Ghana http://ugspace.ug.edu.gh Introductory letter from department 79 University of Ghana http://ugspace.ug.edu.gh Letter from Ethics Committee for the Humanities (ECH) 80