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Abstract
Background and aim The impact of any injury prevention programme is a function of the programme and its implementation. However, real world implementation of injury prevention programmes is challenging. Lower limb injuries (LLIs) are common in community Australian football (community-AF) and it is likely that many could be prevented by implementing exercise-based warm-up programmes for players. This paper describes a systematic, evidence-informed approach used to develop the implementation plan for a LLI prevention programme in community-AF in Victoria, Australia.
Methods An ecological approach, using Step 5 of the Intervention Mapping health promotion programme planning protocol, was taken.
Results An implementation advisory group was established to ensure the implementation plan and associated strategies were relevant to the local context. Coaches were identified as the primary programme adopters and implementers within an ecological system including players, other coaches, first-aid providers, and club and league administrators. Social Cognitive Theory was used to identify likely determinants of programme reach, adoption and implementation among coaches (eg, knowledge, beliefs, skills and environment). Diffusion of Innovations theory, the Implementation Drivers framework and available research evidence were used to identify potential implementation strategies including the use of multiple communication channels, programme resources, coach education and mentoring.
Conclusions A strategic evidence-informed approach to implementing interventions will help maximise their population impact. The approach to implementation planning described in this study relied on an effective researcher-practitioner partnership and active engagement of stakeholders. The identified implementation strategies were informed by theory, evidence and an in-depth understanding of the implementation context.
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Introduction
The need for implementation planning
Injury prevention programmes have little population health impact if they are not evidence-based and used widely.1 Programme effects have been shown to be up to three times higher when programmes are well implemented.2 Without a systematic and evidence-informed approach to programme implementation, conclusions of limited effectiveness will be made based on poor implementation.3 Structured implementation planning frameworks can help to reduce the research-to-practice gap and maximise programme impact by increasing the use of evidenced-based programmes in communities.4 ,5
Sports-related injuries are a significant public health problem6 requiring a systematic approach to their prevention. This should include quantifying the injury problem, identifying the causes and risk factors, developing and trialling interventions and developing implementation strategies to enable evidence-based interventions to be effective in real world settings.1 To date, research across a range of sports, in several countries, suggests that, although evidence-based sports injury prevention interventions are available, they are generally neither widely nor well implemented at the elite, community or school level.7–11
There have been few published implementation or effectiveness studies in sports injury prevention12 and information about specific implementation components is scarce.13 Similarly, the evidence or theory underpinning implementation strategies used in sports injury prevention trials are rarely reported.14
Community Australian football: injury epidemiology and relevant countermeasures
Australian football (AF) is a popular community/recreational participation sport in Australia with a relatively high risk and rate of injury.15 ,16 Lower limb injuries (LLIs) are common in community-AF17 despite the fact that many are potentially preventable.18
A recent review of LLI prevention exercise protocols concluded that an exercise-based warm-up programme including balance and control, eccentric hamstring, plyometric and strength exercises could prevent LLIs in community-AF.18 In response, as part of the larger National Guidance for Australian football Partnerships and Safety (NoGAPS) project,19 a LLI prevention programme (FootyFirst) targeted at male, adult community-AF players was developed. The exercises included in FootyFirst were underpinned by research evidence,18 ,20 expert opinion21 and a randomised controlled trial evaluation of a precursor programme which demonstrated clinically important reductions in lower limb (22%) and knee (50%) injury rates.22 FootyFirst was developed anticipating that it would become a national programme after being trialled in three geographical regions of Victoria, Australia.
To address the research-to-practice gap in the general and sports-specific injury prevention literature,7 ,23 this paper describes the development of an implementation plan for FootyFirst in one arm of the larger NoGAPS study. It also provides general guidance to injury prevention practitioners and researchers in how to plan the implementation of interventions in any context.
Methods
Intervention Mapping (IM) facilitates effective health promotion programme planning, implementation and evaluation.24 IM Step 5, which can be used independently of other IM steps, focuses on planning programme adoption, implementation and maintenance.24 It comprises seven tasks that are operationalised through six core processes.
Building on previous sports safety programme implementation planning research,25 we used IM Step 5 to plan the implementation of FootyFirst in a regional AF league (n=22 clubs) in Victoria, Australia. The IM Step 5 tasks undertaken, and the key questions addressed during the implementation planning, are outlined in table 1.
How the Intervention Mapping Step 5 tasks were applied when planning the implementation of FootyFirst
The seven-person league-specific FootyFirst Implementation Advisory Group (IAG) established in Task 2 comprised the project manager (author AD), a league administrator, a regional game development officer, a community club administrator, two community club senior coaches and a community club high performance manager (who was also a player). The IAG participated in IM Step 5 Tasks 3–7 using the six IM core processes—posing questions, brainstorming, reviewing the literature, using theory, acquiring new data and formulating answers24—to help complete each task.
FootyFirst is ultimately targeted at recreational adult, male AF players (typically aged between 18 years and 35 years) who generally train twice and play one game of football each week. However, because the training of these players is the responsibility of community-AF club coaches, the implementation activities were directed at the senior coaches of all 22 community-AF clubs in one geographical region, where the competition was administered by a single governing league. Implementation planning was undertaken in October–December 2011 with the aim of operationalising the strategies during the 2012 community-AF season.
Results
The outcomes of the seven tasks of IM Step 5, as they applied to planning the implementation of FootyFirst, are summarised in tables 2⇓–4.
Performance objectives, determinants and change objectives for the Reach of FootyFirst among community AF coaches
Performance objectives, determinants and change objectives for the Adoption of FootyFirst by community-AF coaches
Performance objectives, determinants and change objectives for the Implementation of FootyFirst by community-AF coaches
Task 1: Identifying potential FootyFirst adopters and implementers
Given the nature of FootyFirst as a programme,21 and the role of AF coaches in training players to participate safely,8 the senior coaches of the targeted clubs were identified as the primary focus of the implementation activities. Acknowledging the ecological influences on safety programme implementation in community sport,26 state, regional and club administrators, and community coaches, first aid/rehabilitation providers and players, were identified as potential influences on the FootyFirst implementation decisions and behaviour of senior coaches.
Task 2: Establishing a FootyFirst adoption and implementation planning group
Like many sports, community-AF has a hierarchical, top-down model of delivery.27 To leverage this administrative structure, and to obtain high-level support to implement FootyFirst, the project team started Task 2 by gaining national and state-level AF administrators’ endorsement of the project. This was achieved by highlighting that: LLIs are a significant problem in community-AF,17 an evidence-based training protocol could potentially prevent common community-AF LLIs,18 and that injury prevention interventions are only worthwhile if they are widely and well implemented.1
This was followed by regional/league-level endorsement and active participation by the league administrators to recruit influential local AF coaches and other ‘change agents’ to join a league-specific FootyFirst IAG. This group linked the programme developers (the project team) to the programme adopters and implementers (the coaches). Specifically, the IAG provided feedback on the FootyFirst performance and change objectives (Tasks 3 and 5) and contributed to identifying the determinants of FootyFirst reach, adoption and implementation (Task 4). They also brainstormed implementation strategies (Tasks 6 and 7) and provided insight into the context and target audience for FootyFirst implementation.
Only the individual (coach), interpersonal (team/players/other coaches) and organisational (club/league) ecological levels were considered.26 This reflects the significant role that the local context plays in sports policy interpretation and implementation.27
Task 3: Stating FootyFirst implementation outcomes and reach, adoption and implementation performance objectives
The anticipated implementation outcomes were that coaches would: (1) be aware of FootyFirst (reach); (2) deliver FootyFirst to their players (adoption); and (3) deliver FootyFirst to their players as the programme was intended to be delivered (implementation).
The project team developed performance objectives by defining what constituted FootyFirst reach, adoption and implementation among community-AF coaches. The performance objective for programme reach revolved around coaches becoming aware of FootyFirst through promotional, communication and educational activities, and resource distribution (table 2). Programme adoption performance objectives focused on coaches making the decision to deliver, and actually delivering FootyFirst to their players (table 3). Programme implementation performance objectives reflected that regular and high fidelity player performance of FootyFirst would require coaches to incorporate FootyFirst into the routine warm-up performed by their players at every preseason and regular season training session (table 4). The performance objectives were presented to, and endorsed by, the IAG.
Task 4: Specifying determinants of FootyFirst reach, adoption and implementation
The IAG concluded that coach awareness of FootyFirst would be influenced by the information communicated about FootyFirst (ie, the message), who communicated the information (ie, the messenger) and the communication channels used (ie, the media used) (table 2). It was agreed that coach adoption and implementation behaviours could be influenced by personal/individual, organisational, social and environmental factors. This reflects the major concepts of Social Cognitive Theory (SCT) and the idea that an individual's behaviour is dynamic and a function of the interaction between their personal characteristics and the physical and social environments.28 Based on discussions with the IAG, coach knowledge, skills and beliefs, and the team, club and league environments were identified as key determinants of the FootyFirst adoption and implementation behaviour of coaches (tables 3 and 4).
The outcomes of Tasks 3 and 4 were used to construct matrices of FootyFirst reach, adoption and implementation performance objectives and determinants (tables 2⇑–4). Completing these matrices by specifying the FootyFirst reach, adoption and implementation change objectives was undertaken in Task 5.
Task 5: Identifying change objectives for FootyFirst reach, adoption and implementation
Conceptually, the content of each cell in tables 2⇑–4 represents a desired outcome or change in either the internal/personal (eg, knowledge, skills and beliefs) or external/environmental determinants of the FootyFirst-related knowledge and behaviour of coaches. Because the identified determinants are dynamic and interdependent, no cell is self-contained or limited. For example, a coach's skill in implementing FootyFirst is directly related to, and influenced by, their knowledge of FootyFirst and the fit between FootyFirst and their particular club environment (time, space, equipment, player attitude, etc). The change objectives were presented to, and endorsed by, the IAG.
Tasks 6 and 7: Selecting theory-informed, evidence-based and context-specific FootyFirst reach, adoption and implementation strategies
The IAG brainstormed potential strategies to facilitate coaches achieving the change objectives identified in Task 5. The project team reviewed the brainstormed strategies based on available evidence from the research literature, relevant health promotion, injury prevention and implementation science frameworks and theories, and practical context-specific considerations (eg, available budget and resources, workloads, time constraints and preferred communication methods).
Previous studies of coach uptake of injury prevention interventions show that comprehensive coach education can positively influence safety knowledge29 and programme implementation behaviour.30 Coaches are also more likely to implement injury prevention training if they have access to ideas about how to deliver such training to their players.31 The lessons learned from implementing injury prevention programmes in other sports were also used to inform implementation strategy selection.25 ,32 ,33
Although the use of theories and frameworks can enhance programme implementation,34 this can be daunting for non-academics.35 We used the Diffusion of Innovations (DOI) theory36 and the Implementation Drivers (ID) framework37 to guide the review of the brainstormed implementation strategies, based on the recent successful application of both these frameworks in community sport settings.25 ,38 The aspects of DOI considered when reviewing the FootyFirst implementation strategies included: interpersonal and mass media communication channels; opinion leaders and change agents; compatibility with existing practice, culture and values; the relative advantage over existing practices; and the complexity of FootyFirst.36 The ID components considered focused on the need to: build coach competency in implementing FootyFirst (eg, coach education delivered in the preseason, at a local venue by a high profile, local high performance coach); build organisational and administrative systems to support FootyFirst implementation (eg, injury surveillance system); and provide leadership for FootyFirst implementation (eg, club presidents publicly committing to implement FootyFirst).14
The strategies developed to support FootyFirst reach, adoption and implementation among community-AF coaches, the change objectives these strategies were designed to address, and the DOI and ID framework components used to inform these strategies, are outlined in table 5. Some strategies, such as distributing FootyFirst resources to coaches, were selected or designed to address multiple change objectives.
Implementation strategies developed to enhance the Reach, Adoption and Implementation of FootyFirst among community-AF coaches
Discussion
Poor programme adoption and use are often a precursor to poor programme outcomes.24 This paper describes the systematic and iterative process used to develop an implementation plan for an LLI prevention programme in community-AF. The process was based on a partnership between health promotion, implementation science, and injury prevention researchers, and community sports administrators and coaches. The approach was informed by behaviour change theory, implementation science frameworks and published evidence about effective implementation strategies for safety programmes in community sport. This was supplemented with in-depth knowledge of the implementation context and input from the programme end users.
Creating implementation structures is one of the four phases believed to facilitate high quality implementation of any innovation.39 Using IM Step 5, we were able to complete two key steps in this phase–establishing an implementation team and developing an implementation plan39–successfully. In conjunction with a strong researcher-practitioner partnership and a structured method of engaging with programme end users, this enabled the development of an implementation plan specifically designed to bridge the gap between research (top-down) and community (bottom-up) driven programme implementation processes.
Future advances in injury prevention are unlikely to be achieved at a population level without a better understanding of how to implement evidence-based interventions in the real world. In the community sport context, achieving widespread implementation of safety programmes is challenging1 ,27 ,33 and few examples of theory-informed implementation planning are available.25 ,38 ,40
Much of the implementation planning for FootyFirst focused on developing strategies to improve the fit between the programme and the AF coaches who would need to implement it. This process was greatly enhanced by having representatives from multiple ecological levels—including regional, league and club administrators and community-AF coaches—on the IAG. This ensured that the selected implementation strategies were likely to be doable and sustainable within the constraints and context of the league's administration beyond the life of the funded project.
Considerable attention was given to creating supportive and encouraging environments for implementing FootyFirst in the targeted football clubs. This included involving league and club administrators, and well known and respected community and elite level coaches, in the selection and operationalising of the FootyFirst implementation strategies. Based on previous research developing and implementing sports injury prevention initiatives in the US military,41 we anticipated that ensuring FootyFirst was perceived to be compatible with their personal and organisational missions, values and priorities, would enhance the likelihood that FootyFirst would be adopted and implemented by the targeted football coaches and clubs.
Models to translate research to practice can be complex, overly academic and time-consuming when applied in real world settings.35 However, this case study shows that by deconstructing the process into a series of straightforward key questions to be answered (see table 1), it can be relatively efficient and easy to use IM Step 5 to plan the implementation of injury prevention interventions. This was further facilitated by our previous experience using IM Step 5 in a similar setting.25 Nonetheless, the implementation planning process used was more time-consuming than the processes previously used by the administrators of the targeted AF league. For example, convening an IAG, and reviewing and contributing to implementation planning documents were tasks that the league administrators had not previously undertaken. Importantly, the implementation planning process described in this paper could be applied to other injury prevention research and practice settings. In particular, setting-specific and intervention-specific versions of the ‘key questions’ included in table 1 could easily be applied to generate useful, context-specific information to guide the selection of implementation strategies in other settings and with other injury topics. Clearly, the time and resources committed to this process should be commensurate with the scale and size of the project being undertaken.
Other challenges we experienced revolved around the two related issues of the seasonal and volunteer nature of Australian community sport. As the majority of IAG members were busy volunteers at community sports clubs, it was difficult to recruit and engage them before the start of the AF season when most of the implementation planning needed to be done. Many were actively involved in other sports or did not want to get involved in AF-related activities during the off-season. Once the AF season started, it was difficult to find mutually convenient times for all IAG members to meet as many were heavily involved in the considerable tasks of administering or coaching community sport. Strategies used to address this challenge included: the league administrators and a high profile local sports medicine physician (rather than the research team) sending the invitations to join the IAG; clearly specifying the limited time demands that would be made on members of the IAG; negotiating convenient times and venues for IAG meetings to facilitate maximum participation by members; and using email and telephone conversations to get input from IAG members who were unable to attend meetings.
The language of implementation planning, health promotion and behaviour change theory also challenged the IAG as it is very different to the language of community sport. Fortunately, the first two IM core processes—posing planning problems as questions (see table 1) and brainstorming answers using planning group knowledge and experience—are very practical and participatory. This meant that it was possible to frame the whole implementation planning process in the context of the everyday experiences of the IAG members very early in the process.
Full evaluations of the effectiveness, cost-effectiveness and other outcomes, of the implementation planning process, based on the Reach, (perceived) Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework,26 and FootyFirst in terms of its population level impact on LLIs in community-AF are currently underway. Based on the outcomes available to date, the Australian Football League has now endorsed the national roll-out of FootyFirst for 2016. This roll-out will be informed by the process described in this paper.
Conclusion
Injury prevention programme outcomes are determined by a combination of the effectiveness of the programme and the effectiveness of its implementation. IM Step 5 is a practical, useful and scalable implementation planning protocol that, when used creatively and flexibly, can lead to the development of theory-informed and evidence-informed, and context-specific implementation plans for injury prevention programmes. Our experience demonstrates the critical importance of researchers, practitioners and community end users collaborating early in the implementation planning process. Even when applied to sport, a setting largely unfamiliar with health promotion concepts, this case study demonstrates that IM Step 5 encourages the use of processes that place equal value on the knowledge, skills and experience that these different groups bring to the implementation planning process.
What is already know on this subject
Programme impact is a function of the efficacy of the programme and the effectiveness of its implementation.
Although many evidence-based sports injury prevention interventions are available, few are well implemented in the real world.
What this study adds
High quality implementation planning can be achieved with a strategic, ecological approach based on a partnership between programme developers (researchers) and programme implementers (gatekeepers and end users).
Intervention Mapping Step 5 is a useful, feasible and scalable protocol to use when planning the implementation of injury prevention interventions.
Acknowledgments
The authors thank the Australian football coaches, players and administrators who assisted in the developing the FootyFirst implementation plan outlined in this study.
References
Footnotes
Twitter Follow Alex Donaldson at @AlexDonaldson13 and Caroline Finch at @CarolineFinch
Contributors All authors contributed to the writing and critical review of this manuscript. AD was responsible for managing the implementation planning process and liaising with the Implementation Advisory Group. Final approval of the contents of the manuscript was obtained from all authors. All authors take responsibility for the integrity of the work from conception to publication.
Funding This study was funded by a National Health and Medical Research Council (NHMRC) Partnership Project Grant (ID 565907) with additional support (in cash and in kind) from the project partner agencies: the Australian Football League (AFL); Victorian Health Promotion Foundation (VicHealth); NSW Sporting Injuries Committee (NSWSIC); JLT Sport, a division of Jardine Lloyd Thompson, Australia; the Department of Planning and Community Development; Sport and Recreation Victoria Division (SRV); and Sports Medicine Australia National and Victorian Branches (SMA). AD's salary was funded by this research grant. CFF was supported by an NHMRC Principal Research Fellowship (ID1058737). BJG was supported by an NHMRC Career Development Fellowship (ID1048731). JC was supported by an NHMRC practitioner fellowship (ID058493). The Australian Centre for Research into Injury in Sport and its Prevention (ACRISP) is one of the International Research Centres for the Prevention of Injury and Protection of Athlete Health supported by the International Olympic Committee (IOC).
Competing interests None declared.
Ethics approval Monash University Human Research Ethics Committee.
Provenance and peer review Not commissioned; externally peer reviewed.