Table 3. Categories identified in interviews with middle school athletes, parents, and staff related to the category of “sport culture”.

Category	Example quotes
Participation Athletes (n = 18/19) Parents (n = 18/20) Not a category for staff	Reasons why athletes want to participate “My dad was always really big on things like baseball and football and all that. And though my parents were concerned about safety issues, I just kind of got into it really quickly and then continued it.” (Athlete #12022) “A lot of my friends were doing it and I wanted to do sports and so I decided to do that.” (Athlete #12034) Reasons why parents want their children to participate “…comradery that I think a team provides has really helped him navigate some of the tumultuous transitions of adolescence (Parent #11056)” “the environments are really around the development of the child, not necessarily of the development of the athlete” (Parent #21023) “his mother and I really wanted to make sure that sort of physical activity was part of how he knew the world to be, so we started him playing soccer when he was probably like 3” (Parent #11056)
Role/Engagement Parents (n = 19/19) Staff (n = 18/18) Not a category for athletes	Staying engaged as parents “School soccer, they practice every day after school except for Friday. But actually their games are during the week…We don’t even see him until after 5:00! … And then he’s also doing club soccer which is practices are actually three times a week in the evening. So, when we had both, it was crazy … he comes home, has something quick to eat and then goes to the next one.” (Parent #11019) “If you have a parent who steps up to be sort of an administrative person who can stay on top of that, the coach can reach out to you, for example, that works better. So, we’ve had a variety of experiences with that.” (Parent #31015) Finding coaches “They were from the community, either from [nearby university] or someone who worked in the area or whatever. Sometimes it’s a parent that comes and becomes a coach. So they search for coaches not just within the school system but throughout because I think sometimes they have a hard time finding coaches too.” (Parent #31020) “Most times you’re going to want to have a teacher who works in the school to be a coach at the same time. It’s mostly for discipline reasons I’d say more than anything else. Just if there’s any problems with a kid with academics or acting out in class then the teacher is going to reach out to you and you can take them away from the sporting event or whatever, talk to them or make them have some sort of consequence for their actions. At the school right now though I think we do a lot of coaches from the community and [nearby university] coaches. I know our Lacrosse team had girls who were on the club team at [the nearby university]. I know that our Track coach was a [nearby university] student. Sometimes it’s hard to get those positions filled. I know our athletic director tries to make sure it’s within the school but he has to use what he can get. I mean we almost lost the Lacrosse team because we couldn’t get a coach until the very last minute. We got a good Lacrosse coach though.” (Staff/Coach# 23003) Ensuring safety and education “teacher first, coach second” (Staff/Coach# 13003) “I worry so much about educating the children. But it’s if there’s an accident, you’re putting attention all on that child over the next 24 hours, 36 hours. And we timeframe to make sure that they didn’t get injured or have a concussion. Um, during practice, you’re just looking for safety stuff. You’re not going to say “hey, be careful you can get a concussion from this”. You can’t live like that. But just making sure that safety operations are in place, any sort of dangers or…you’re taking care of that beforehand so that hopefully they don’t occur.” (Staff/Coach# 73003) “I think a lot of that would fall on the athletic director to make sure that all of the coaches in that school are aware of all of the requirements. All of the training, all of their certification, taking online classes, or whatever. So, I think it comes from…the culture needs to be established up top and fall down.” (Staff/Coach# 53005) The limits as a school nurse I’m a nurse and I’m not allowed to diagnose. So I’d never say “I think they have a concussion” because that’s medical practice and I can’t do that. So, I would say what their symptoms are, if the coach came to me, and “I’d strongly suggest and recommend that you go get medical attention.” That’s what I would say. (Staff/Nurse #14001) Our job as nurses is not to monitor to make sure people are doing the report. Our job is to make sure that these kids are OK and they’re going back OK into healthy and injury-free as possible… (Staff/Nurse #34001) I’m treating symptoms…And even when I have documentation, as a nurse I’m still treating symptoms. I’m not an M.D. that can do much beyond that. We’re following what the M.D.s are saying to do. (Staff/Nurse #44001)
Competitiveness Athletes (n = 19/19) Parents (n = 19/20) Not a category for staff	Competitiveness of youth sports “over time…sports have gotten more competitive for kids, a lot more competitive, even like club sports” (Parent# 31020). “I think it’s as competitive as the NFL! I mean they’re out there, they want to be the team, they want to win. I’m always amazed at whatever age it was they were interested in winning than anything else” (Parent# 21006) “The school thing is very competitive in the sense that it’s sort of bragging rights … people want to win and at the end of the whole thing, one team wins the whole thing…But then club is like a totally different cup of tea. It’s like there’s different levels. There’s silver, gold, bronze and then you try out, you get placed at whatever level. And then they go out and play all different types of games, sometimes tournaments in other states and things like that. So, in some ways it’s more competitive” (Parent# 11019) “it wasn’t really fun to like be there socially because everybody was just focused on…practice, practice, practice” (Athlete# 12051) Focusing on fun over competitiveness “I really like how competitive [sports] are, which can get dangerous at points I suppose. But I don’t know, it’s a way to get your emotions out and a way to work out I guess. (Athlete# 12002)” “Oh, we were horrible. We won two games each season. It was just us having fun and to keep moving.” (Athlete# 32015) “Cross-country is like everybody is a winner. I mean sometimes the kids will have like “team pride.”… the girls and boys run separately but they stay and cheer each other on. It’s the opposite of competitive even against the other schools, like their rivals. They all know them.” (Parent# 21009) “Ultimate [Frisbee] was like “This is fun.” I don’t know. The sport dynamic, you could feel it. It was different … Like the kids were still smiling and cheering each other on. I don’t know how to explain it.” (Parent# 11022) Competitiveness putting athletes at risk for injury “[Competitiveness] could lead to a situation even in a safe sport like cross-country where you can get a concussion” (Parent# 31017) “I think a lot of it is the ‘walk it off’ attitude. It’s a lot of the time what you need to do; just get up and keep going and you’re fine. You might hurt for a minute.” (Parent# 31004) Role of coaches and schools to monitor sports “I think any coach has a big role in that. It’s kind of like a leader in a work situation because they set the tone. I mean we’ve been very fortunate with both my kids to have a lot of coaches who are very positive. It’s about bringing a positive spirit. It’s not about winning. But there’s also, I’ve seen a lot of coaches that aren’t. And that really trickles down pretty fast. It sets the tone for the kids. It shows what they are focusing on. It shows even what skills and drills they’re doing. So, I think who the coaches are and how they lead is critical. And I think that’s really important. I think that if you have the same coach and you play the same sport, in middle school if you’re playing for two years or three years, if you have the same coach then they know you already so there’s continuity which can be really nice in building relationships.” (Parent# 31020) “[My school] does a pretty good job of letting them determine how competitive they’re going to be. And that’s good. We had a couple of really—- I don’t even know if “competitive” would be as good a term as just “interested.” Especially one of the really gifted athletes on the team, the one parent was just really into it. But yet at the same time it was more about the son than it was about winning or anything like that.” (Parent# 11002)
Safety Athletes (n = 19/19) Parents (n = 20/20) Staff (n = 18/18)	Perspective on injuries “The parents are a bit more concerned about like the tangible injuries, like torn ACL’s, broken ribs, broken arm, broken leg. The injuries that you can’t see, no one talks about…Because you can’t see it” (Parent# 41003) “You’re going to get hurt eventually sometime in the season on way or another.” (Athlete# 12002) Changing culture “just a lot more about prevention and speaking…speaking to [athletes] about, like what we talked about—the rebounding techniques. And things to avoid concussions. In the past, I guess we were aware of them, if they happened. But we weren’t super active or proactive about preventing them. And so, I think the prevention aspect has definitely increased a lot.” (Staff/Coach# 43003) “So, you know, we like to continue to enhance that and share that with the other schools we work with. And make sure the district is, you know, focused on those efforts as well. And hopefully that district, our district, is you know, sharing what they know with other districts and it just spreads. Or we’re getting information from other districts that are doing things a little bit better, so we are on the same page and always promoting the welfare of the student-athlete.” (Staff/Coach# 53003) The role of all individuals within MS sports “Like when, at the very beginning when we like made the team we like sat down and we talked about a lot of things like what we’re going to do in practice and one of those things was like make sure we don’t get hurt and like and we talked about concussions there and stuff.” (Athlete# 22023) “Well, our coaches, they watch pretty carefully. They’re like ‘I want to see if anyone is covering something up because it’s not as important to me that we win as your safety.’” (Athlete# 32015) “Yeah. So, I mean I think that a sport safety culture you know does come from a coach, but also from the school and kind of the community … I guess I would say that as a parent it’s also you know, my responsibility to—kind of be checking in with my kid and you know during coaching orientation—and like parent orientation to be kind of listening for safety type messages.” (Parent #21023) “I think parents definitely have a role to play—In sort of having the expectation that, you know, safety is the priority over winning and really over anything else. As parents we should demand that.” (Parent# 11056) “I think the refs needs to take the forefront on that. And the refs need to be more receptive to the coaches. Because the coaches are seeing…you know, the refs are looking for wherever the ball is for that call. Whereas, coaches are watching everything. … And parents should be able to let either coach or the ref know without assuming that they are taking on too much of a…they’re being too crazy of a spectator.” (Staff/Coach# 73003) The role of policy and rules “Just the basic rules like when the whistle blows the play stops, with no more hits or anything. There’s a certain set, like there’s like a certain limit where if you do something too bad like hit, like hit too dirty or have like an attitude, they’ll throw a flag.” (Athlete# 42003) “Like be respectful of other people’s space I guess. When you’re playing soccer there’s rules like you can’t high kick where your cleat goes too high in the air because there have been times where like people get a cleat in the mouth or in the head and that can cause concussions or losing teeth.” (Athlete# 12022) “I think that if players know they’ll get a foul call on them if they do do something dangerous, then they’ll be less likely to do it.” (Athlete# 22006) “some schools [changed] how they practice to reduce the occurrence of concussions during practice” (Parent# 11045). “I’ve hardly ever seen it. It’s just like a different, like it’s not in the game. When the kids know that they can’t head it they just don’t. I can’t even think of a time where a kid headed a ball and they blew the whistle. I’m almost certain that in school, because I go to all the school games and all that, I don’t think there’s any heading at all.” (Parent# 11019) “So, if we suspect a student has a concussion we have to report it right away to the athletic director and to the nurse and possibly the principal just to keep them in the loop. Once we do that, we go through the concussion protocol and they can’t come back.” (Staff/Coach# 13003) Issues with implementation “I think that a lot of the coaches now are if there’s concern about it they’re taking them out. They’re monitoring. They’re asking the questions initially, having them sit it out for a little bit, continuing to monitor them. If at some point they’re still not having any symptoms and they say they’re fine then some will let them go back in. Some there’s protocols now, like not for the rest of the game depending on how significant it is. But I’m not sure how often that’s done. And again, that’s self-reporting and a lot of kids they want to play. So it’s ‘nope, nope. I’m fine.’” (Parent# 31020) “If it’s not a great ref then sometimes [teams] won’t play by the rules or are more aggressive and don’t get called for it.” (Athlete# 22040). “I think sometimes winning takes over safety of children—and then so, you know, they might actually have a concussion, but nobody will actually acknowledge it because they want to make sure that they win.” (Staff/Coach# 23006) “There’s so many rules in place for middle school—like oh you can’t do that, you can’t do that cause they might get hurt. Well why allow it in college? It seems like if it was fine in high school it should be fine in middle school. So I think there is a little too much rules.” (Athlete# 72013)