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Recent commentary in the BJSM has argued that a key challenge for future sports injury prevention is to reduce the ‘research to practice’ gap.1 Unfortunately, very few examples of this type of research actually exist. In this issue, Myklebust et al 2 describe their approach to anterior cruciate ligament (ACL) injury prevention in Norwegian Handball over the past 13 years. This is one of the first published papers on the long-term outcomes of a sports injury prevention intiative that has shown promising efficacy in controlled trials.3 While this paper describes an impressive intial research effort and outstanding example of long-term follow-up through an ACL Injury Surveillance Programme, it also highlights challenges associated with conducting sports injury prevention implementation research.
Gaps in sports injury prevention implementation research
Like other reports of the implementation of sports injury prevention interventions,4–8 Myklebust et al have listed the implementation activities undertaken without providing details of theoretical frameworks, specifc evidence or guiding principles used to inform selection or operationalisation of these activities. While considerable effort is often invested in describing the details of, and the evidence-based underpinning, interventions, implementation research also requires detailed information about what specific implementation strategies were put in place, why and how they were selected and delivered, and how effective they were in reaching and influencing the behaviour of the targeted audience.9 It is insufficient to describe implementation activities in general terms only (e.g, ‘instructors had been familiarised with the programme during a 2 h seminar, in which they received theoretical and practical training on how to conduct the programme’3 and ‘Football/Soccer coaches received SoccerSmart education and the above resources from a trained presenter/facilitator’5). The important details about how these strategies were operationalised should also be provided.
According to Fixsen et al 10 ‘effective implementation strategies at multiple levels are essential to any systematic attempt to use the products of science to improve the lives of children, families, and adults. That is, change at system, organisation, programme, and practice levels’ (p.vi). Even though this concept is not new to sports injury prevention research,11 ,12 most published sports injury prevention interventions, including those of Myklebust et al,2 revolve around a combination of disseminating information or resources (e.g, DVDs, websites, posters and manuals) and educating or training coaches (e.g, workshops, seminars and courses). This is despite the consistent evidence that these activities alone do not generally result in positive implementation (i.e, changes to practitioner behaviour) or intervention (i.e, benefits to programme participants) outcomes.10 While it can be difficult for researchers to engage government or sporting organisation in implementation activities targeting organisational structure and policy, and it can be argued that some implementation is better than waiting until everything is in place, this does not mean that these types of activities should not be attempted. Perhaps investigators should begin to report the challenges experienced when attempting to undertake system-wide implementation actives and to engage with other sectors as a reminder to the rest of us of the need to keep plugging away until we learn to do it better.
Learning from implementation science
Although implementation science is still an emerging and rapidly developing field, a number of its underpinning concepts have already appeared in the sports injury prevention implementation literature. These include the importance of: understanding the implementation context;11 ,13 ,14 adopting a multilevel or ecological appoarch to implementation activities11 ,12 and engaging intervention end-users in the planning and operationalising of implementation activities.6 ,7 ,15 These are all requirements for successful intervention implementation in any setting, as articulated in the implementation science literature.10
One area of implementation science that has yet to receive much attention in the sports injury prevention field, however, is the notion of implementation drivers, which exist independently of the quality of the programme, practice or policy being implemented.16 ,17 These include Competency drivers—staff/practitioner (e.g coach, sports trainer, policy maker and sports physician) selection, staff training, coaching and consultation, and staff performance evaluation; Organisational drivers—systems interventions, facilitative administration and decision support systems; and Leadership drivers—technical and adaptive. These drivers act in an integrated and compensatory way to drive widespread, high-fidelity implementation of evidence-based practices across relevant sectors (see figure 1).17 ,18
As suggested previously, most sports injury prevention implementation research has focused on activties that would fall under the umbrella of training where potential intervention implementers—particularly coaches—are provided with educational opportunities and information and then expected to implement the prescribed intervention in their real-world setting.
Application to the planning of delivery of a neuromuscular training programme
To illustrate the relevance of these implementation drivers to a sports injury prevention intervention, table 1 shows how they could be applied to planning the delivery of a neuromuscular training programme to prevent lower limb injuries in community Australian Football.19
Appropriate attention to the implementation drivers should result in knowledgeable and skilled coaches who can implement the intervention well because there are systems, policies, procedures and leadership strategies in place at multiple levels that create an environment that encourages and supports them in their intervention implementation efforts.
Take home message
Similar to the RE-AIM Sports Setting Matrix (table 2)11 ,20and Step 5 of Intervention Mapping,21 ,22 the implementation drivers17 demonstrate to sports injury prevention researchers the potential benefits of embracing implementation science more broadly. Unless we do so, it is unlikely that we will do justice to our efforts to understand and apply what does and does not work while implementing evidence-based sports injury prevention interventions in the real world.
The authors would like to thank Dean Fixsen for providing the Implementation Drivers triangle figure as figure 1 in this paper.
Funding This work was funded by a National Health and Medical Research Council (NHMRC) Partnership Project grant (ID: 565907) which included additional support (both in cash and kind) from the following project partner agencies: the Australian Football League; Victorian Health Promotion Foundation; New South Wales Sporting Injuries Committee; JLT Sport, a division of Jardine Lloyd Thompson Australia Pty Ltd; Department of Planning and Community Development—Sport and Recreation Victoria Division; and Sports Medicine Australia—National and Victorian Branches. Caroline Finch was supported by a NHMRC Principal Research Fellowship (ID: 565900). AD was supported by a Monash Research Accelerator grant from Monash University.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.