Background This paper describes the development of a theory-informed and evidence-informed, context-specific diffusion plan for the Mayday Safety Procedure (MSP) among community rugby coaches in regional New South Wales, Australia.
Methods Step 5 of Intervention Mapping was used to plan strategies to enhance MSP adoption and implementation.
Results Coaches were identified as the primary MSP adopters and implementers within a system including administrators, players and referees. A local advisory group was established to ensure context relevance. Performance objectives (eg, attend MSP training for coaches) and determinants of adoption and implementation behaviour (eg, knowledge, beliefs, skills and environment) were identified, informed by Social Cognitive Theory. Adoption and implementation matrices were developed and change-objectives for coaches were identified (eg, skills to deliver MSP training to players). Finally, intervention methods and specific strategies (eg, coach education, social marketing and policy and by-law development) were identified based on advisory group member experience, evidence of effective coach safety behaviour-change interventions and Diffusion of Innovations theory.
Conclusions This is the first published example of a systematic approach to plan injury prevention programme diffusion in community sports. The key strengths of this approach were an effective researcher–practitioner partnership; actively engaging local sports administrators; targeting specific behaviour determinants, informed by theory and evidence; and taking context-related practical strengths and constraints into consideration. The major challenges were the time involved in using a systematic diffusion planning approach for the first time; and finding a planning language that was acceptable and meaningful to researchers and practitioners.
- Sporting Injuries
- Injury Prevention
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The merits of strategically planning how to translate research evidence, policy decisions and safety programmes into practice, to achieve sustained population health improvements, have been debated for some time.1–3 However, sports-injury prevention translation research has only recently received attention4–7 and there are few published examples of sports injury implementation and effectiveness studies.8
The Australian Rugby Union (ARU) introduced the Mayday Safety Procedure (MSP) in an attempt to achieve a nationally recognised call and response to potentially dangerous scrum situations. The MSP encourages a quick release of pressure in a ‘standing’ scrum and a controlled ‘unpacking’ of the scrum to avoid flexion or rotation of the neck of the potentially injured player. It was developed in consultation with medical, exercise physiology, rugby coaching and biomechanics experts9 and is included in ARU medical and safety recommendations10 and compulsory coach and referee training.11
Community rugby union (hereafter referred to as rugby) coaches know about the MSP but they do not have a good written recall of the key criteria nor do they regularly train or assess player competency in it.12 The challenge of translating rugby safety policy into changes in coach and player behaviour is not limited to the MSP nor to Australia.13–16
The two authors (AD and RP) worked closely with two ARU representatives responsible for administering rugby in a single region in regional New South Wales, Australia, to develop a theory-informed and evidence-informed, context-specific diffusion plan to encourage and support coaches to train their players in the MSP. This paper describes the development of that diffusion plan.
The Intervention Mapping (IM) health promotion programme planning protocol17 includes a step (Step 5) dedicated to planning programme translation. It comprises of seven tasks and is operationalised through six core processes (figure 1). IM Step 5 was used in this project to plan improved diffusion of the ARU MSP policy.
When applying the IM protocol, it is important to distinguish between the programme (to be adopted and implemented) and the intervention (to facilitate programme adoption and implementation). In this project, the programme was defined as ‘training rugby players in the MSP’ and the intervention was ‘the planned activities undertaken to enhance the likelihood that rugby players would be trained in the MSP’.
The tasks undertaken by the project team (the two authors and two ARU community-level administrators) following the IM Step 5 protocol and how they were applied in this project are outlined in table 1.
The project team undertook tasks 1–5. The advisory group established in task 2 reviewed and provided advice on the work of the project team, and participated actively in tasks 6 and 7. The core processes of IM (see figure 1) were applied throughout, particularly during tasks 4 and 6 (table 2).
This was the first time that the ARU had applied the IM protocol. To ensure that the process was manageable, the intervention was targeted on one geographical region where the competition was administered by, and all clubs were affiliated to, a single regional governing body. Diffusion planning was done during October 2010–February 2011 with the aim of undertaking intervention activities during the 2011 rugby season.
The University of New South Wales Medical and Community Human Research Ethics Advisory Panel approved the study.
The outcomes of undertaking the seven tasks of IM step 5 described in table 1 are presented below.
The project team identified the regional rugby association, regional rugby referees’ association, individual referees, club administrators, coaches and players as potential programme adopters and implementers. Coaches of senior rugby teams were identified as the primary focus of intervention activities because of their influence on player safety and training attitudes and behaviours,18–21 and their role in training players in safety.22
Other potential programme users and gatekeepers (eg, players, referees, first-aid providers and club and regional association administrators) were considered only in relation to their influence on the coaches’ MSP decisions and actions. Figure 2 provides an ecological or systems overview of programme adoption and implementation from the perspective of the coach as the primary adopter or implementer.
The project team did not actively engage with the range of potential programme adopters and implementers at various ecological or system levels until the end of task 5. This was because the identified people were nearly all volunteers with limited capacity to participate in this project and it was agreed that the most valuable contribution that they could make would be in tasks 6 and 7 (figure 1). Also, the ARU representatives on the project team were extremely knowledgeable about, and experienced in community rugby administration, coaching and playing, and it was believed that they could represent the views of these groups during the initial diffusion planning tasks. Influential organisations (eg, regional rugby and referee associations) were informed of project progress and knew that they could actively participate in the later tasks.
During task 2, the project focused on the individual, interpersonal and organisational ecological levels only (figure 2), as they related to coaches. This kept the scope within one geographical region and within the management jurisdiction of the ARU administrators on the project team. This approach reflected the significant role that local context plays in sports policy interpretation and implementation.23–25
Adequate programme adoption and implementation, based on the experience of the ARU representatives on the project team, was defined as coaches delivering “at least four MSP training sessions to players before the start of the 2011 season (ie, in the preseason),” and “at least one MSP practice opportunity every 4 weeks during the season,” respectively.
Programme use outcomes and programme adoption and implementation performance objectives were identified by asking “What do coaches need to do to constitute program adoption or adequate program implementation?”
The expected programme outcomes were that coaches would (1) decide to deliver MSP training to their players (adoption) and (2) actually deliver MSP training to their players (implementation).
The specific performance objectives describing what coaches needed to do to adopt and implement the programme are listed in the left-hand columns of the matrixes in tables 3 and 4, respectively. Performance objectives for programme adoption revolved around coaches becoming aware of the need to train players in the MSP and coaches themselves attending training on how to deliver MSP training to players (table 3). Programme implementation performance objectives (table 4) reflected that training players in the MSP would require coaches to schedule and deliver the appropriate number of MSP training sessions and practice opportunities to players in the preseason and regular season.
The determinants of coach programme adoption and implementation were specified by asking “What is likely to influence whether coaches adopt and implement the program?” The potential influences on coaches were explored using IM core processes (figure 1). After brainstorming a list of answers to the question and considering existing coach MSP-related knowledge and practices,12 it was concluded that coach programme adoption and implementation behaviours could be influenced by personal and individual factors (knowledge, beliefs, skills, etc) and by social, environmental or organisational factors (resources, policies, training, time, etc). This is consistent with Social Cognitive Theory (SCT) and the idea that an individual's behaviour is dynamic and is simultaneously and continuously influenced by the person and the environment.26
When working in partnerships it is important to learn to ‘speak each other's language’.27 It became clear during project team discussions that some of the language of the SCT (eg, reciprocal determinism, expectancies, self-efficacy, etc) was not meaningful in the community sports sector. As a result, significant effort was made to ensure that the language used was easily understood by the end-users while still adequately reflecting the underlying SCT constructs. The broad determinants of knowledge, skills, beliefs and environment were identified as key influences of coach programme adoption and implementation behaviour that reflected several key ideas underpinning SCT (table 5).
The results of tasks 3 and 4 were then used to construct a matrix which served as a template for completing Task 5.
Specific programme adoption and implementation change objectives to be achieved by coaches are contained in the cells of tables 3 and 4, respectively. Conceptually, these represent a mechanism for creating changes in both the personal (eg, coach knowledge, skills and beliefs) and environmental factors that will influence coach behaviour.
Tasks 6 and 7
After the project team completed the programme adoption and implementation matrices, the advisory group—comprised of a Regional Rugby Union Association (RRUA) representative (employed administration officer), a Referees’ Board representative (also an active referee), a coach, a player and a club administrator—reviewed the matrices and approved the change objectives. They then brainstormed potential methods and strategies to facilitate coaches achieving the identified change objectives by asking: “What could be done to help, support or encourage coaches to achieve the agreed change objectives?” To ensure that the suggested strategies had some basis in evidence, theory or experience the advisory group also asked: “Why is a particular method or strategy likely to work?”
The project team then accepted or rejected the brainstormed methods and strategies based on available evidence from the research literature, diffusion of innovations (DOI) theory28 and practical considerations (eg, project budget, skills of those who would be operationalising the strategies and the volunteer nature of the target group).
The literature review revealed that coach education can positively influence their safety knowledge and behaviour,29 and that rugby injuries can be reduced through comprehensive coach education.30 In addition, netball coaches have reported that the likelihood of training players in safety strategies increased if coaches had access to ideas about how to deliver such training.31 A review of the broader injury prevention literature highlighted the importance of taking a multifaceted approach including behavioural or educational, and policy, rule, regulation or law-based interventions.32 This has been advocated in sports injury prevention generally33 and recommended and implemented to prevent neck and spinal injuries in rugby specifically.15 ,16 The lessons learnt from the implementation of a comprehensive New Zealand rugby injury prevention programme—including the importance of: partnerships and actively engaging with relevant stakeholders; a multifaceted approach; using existing infrastructure; capitalising on external influences; and using plain language that had meaning for the programme adopters and implementers16—also informed method and strategy selection.
Although the idea of using theories and frameworks to inform the planning of programme implementation and dissemination activities can be daunting for those in non-academic settings,25 their use can enhance implementation and dissemination activities.34 DOI28 was identified as an appropriate theoretical framework to guide intervention strategy selection and planning in this project because of its application in previous health promotion programme diffusion and dissemination research.35 ,36 In addition, preliminary project team discussions identified that DOI was meaningful for both the academic and practitioner team members. The particular aspects of DOI that were applied to the selection, assessment and modification of intervention strategies included the continuum of innovation and stages of adoption principles, multiple communication channels, perceived programme characteristics (eg, compatibility, relative advantage, trialability, observability and complexity) and opinion leaders or change agents. The specific intervention strategies developed to support programme adoption and implementation among coaches in this study, and how DOI was used to inform these strategies are outlined in tables 6 and 7.
Achieving widespread implementation of injury research outcomes or centrally developed safety policies and programmes in community sports is challenging.13 ,15 ,16 ,23 ,24 ,37 However, despite the use of dissemination and implementation theories and frameworks being recommended as a way of improving the uptake of evidence-based interventions, examples of theory-informed attempts to address this problem in community sports safety are not readily available. Although some studies have developed sports-safety interventions using health promotion planning frameworks, including IM,15 ,38 ,39 we believe this is the first study to focus specifically on planning the diffusion of a sports-safety programme within a sporting organisation.
The main strength of the process outlined above was that it involved a structured approach underpinned by a combination of behaviour change theory and published evidence, complemented by an in-depth knowledge of the programme and intervention implementation context. Furthermore, it divided the program diffusion planning process into manageable and pragmatic steps based on answers to the straightforward questions outlined in table 8.
Anecdotally, community sports administrators have reported frustration with usual or traditional programme and policy diffusion strategies used by international, national, state and regional governing bodies and government departments (health, sport and recreation and local government). Typically, these tend to jump directly from identifying what programme adopters and implementers need to do, to implementing strategies to enhance adoption and implementation without asking and answering the other questions highlighted in table 8. This could be described as a ‘miracle’ diffusion plan (figure 3) often overly reliant on information dissemination, education and awareness raising as behaviour change strategies and a top-down communication process.
Understanding the implementation context and the perspective of the intervention end-users are integral to the successful translation of sports injury prevention research.37 ,40 In this project, an ‘adoption and implementation planning group’ was established with representation from all ecological or system levels of rugby considered likely to influence coach behaviour. This helped to ensure that the final diffusion plan was ‘owned’ by those who would ultimately implement it and that the actions and strategies included were likely to be doable and sustainable within the constraints and context of the region's rugby administration beyond the life of the funded research project.
The diffusion plan development process and outcomes described here were facilitated by the fact that the problem addressed was identified by the ARU, and they actively contributed to the development of a context-specific solution. This, in conjunction with a strong researcher–practitioner partnership and a structured method of engaging with the programme end-users, enabled the development of a diffusion plan that might bridge the gap between research (top-down) and community (bottom-up) driven programme implementation processes.33 ,41 In this case study, the application of the IM Step 5 protocol facilitated an effective working partnership between sports injury prevention scientists and community sports development experts, linking theoretical understandings of implementation and behavioural science with a comprehensive understanding of the programme implementation context.
Research translation models have been criticised as being too complex, academic or time consuming for application in real-world contexts.25 Following the IM Step 5 protocol for the first time was certainly time consuming and the language of behaviour change theory and health promotion planning was challenging for researchers and practitioners alike. It took more time and a different way of thinking compared with how community sports administrators would normally plan the diffusion of a safety programme. However, it would be reasonable to expect that this process would be much more efficient when undertaken again. In addition, a strength of IM is that the first two core processes (figure 1)—posing planning problems as questions and brainstorming answers using current planning group knowledge—are not overly academic, and a participatory planning group and linkage system is established early in the process. This helps to ensure that the needs and capacities of the end-users and the complexities of the implementation context are considered from the start of the implementation planning process. Programme impact and outcome is a function of programme effectiveness and implementation.17 ,42 Therefore, although it may initially seem time consuming and costly, investing in planning the implementation of evidence-based sports-safety programmes and using recognised implementation planning frameworks, will probably improve their impact significantly.
Timing is crucial when developing and implementing new ways of planning injury prevention programmes,16 and a sense of urgency is required to facilitate significant change within systems and organisations.43 We believe that the timing was right and there was sufficient urgency for the ARU to commit the necessary resources to testing the new program diffusion planning process described here. Not only was there new evidence highlighting the lack of success in translating organisational safety policy into practice within community rugby,13 but there was also anecdotal evidence of rugby administrator frustration based on their experience of disseminating policies and programmes to clubs and coaches, only to see very little change in behaviour and practice. We also believe that the ARU administrators who invested in this project could see the long-term benefits associated with improving programme diffusion processes within their organisation, above and beyond the immediate improvement in player MSP competence.
There is a growing awareness that sports-safety and injury prevention programme outcomes are determined by both the effectiveness of the programme and the effectiveness of its implementation. The IM Step 5 protocol is a practical and useful process that, if used creatively and flexibly, can lead to the development of theory-informed, evidence-based and context-specific program diffusion plans. IM stresses the importance of researcher, practitioner and community end-user collaboration early in the planning process. It also encourages the use of processes that place equal value on the knowledge, skills and experience that these different groups bring to the diffusion planning process.
Currently, we are evaluating the outcome of implementing this diffusion plan in a single region during the 2011 rugby season to see if investment in the strategic planning process for diffusion of the MSP was warranted.
What are the new findings?
This is the first published, detailed example of the application of a strategic process to plan the diffusion of sports-safety intervention in a community sports setting.
Step 5 of the Intervention Mapping health promotion programme planning protocol is a useful framework to plan interventions to facilitate the adoption and implementation of sports injury prevention programmes.
Researcher–practitioner partnerships are a cornerstone to adoption and implementation planning to ensure theory, evidence and implementation context are all given appropriate consideration.
Finding a language that is meaningful to all stakeholders in an implementation planning partnership is a key challenge.
The authors wish to thank Mr John Searl and Mr Matthew Johnston for their assistance in developing and implementing the diffusion plan, and for helpful advice during the preparation of this paper. We also thank the rugby referees, coaches, players and administrators who participated in this study.
Contributors Both the authors (AD and RGP) made substantial contributions to the conception and design of the study; the acquisition, analysis and interpretation of data; and drafting and revising the manuscript. Both the authors have given final approval of the version to be published.
Funding This research was funded by the NSW Sporting Injuries Committee.
Competing interests None.
Ethics approval The Medical and Community Human Research Ethics Advisory Panel at the University of New South Wales.
Provenance and peer review Not commissioned; externally peer reviewed.
▸ References to this paper are available online at http://bjsm.bmj.com
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