Participants

All 10 AFLW clubs participating in the 2019 AFLW season were included in this programme implementation evaluation (figure 1). AFLW players and club personnel responsible for designing and delivering injury prevention programmes (eg, physiotherapist, high-performance coach, medical doctor) were invited to participate in the online survey and/or semistructured interviews. After four new teams were introduced to the AFLW competition in 2021 (n=14 teams), all 2021 AFLW players were invited to complete an additional survey to evaluate programme awareness, implementation and perceived implementation barriers.

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Figure 1

Timeline of data collection, sources and RE-AIM evaluation. *≥2 AFLW players per club (range 2–24). **≥1 AFLW staff member responsible for injury prevention per club (13 rehabilitation/medical, 12 high-performance professionals). AFLW, Australian Football League for Women; n, number of participants/approximate total number in 2019 AFLW league; RE-AIM, Reach, Effectiveness, Adoption, Implementation and Maintenance.

The prevention programme: Prep-to-Play PRO

Stakeholders across many ecological levels of the AFLW system (organisation, team, player) worked together to create Prep-to-Play PRO and develop an implementation plan to support real-world use.2 10 Elements of Prep-to-Play PRO and its implementation strategy that differ from other injury prevention programmes include: (1) stakeholder partnership, (2) co-design, (3) five standalone components, (4) set of recommendations (ie, not prescriptive).10 11 Programme and implementation strategy development have been reported in detail.11 Briefly, implementation strategies were guided by AFLW player and staff focus groups, research team expertise and available resources. Therefore, a range of evidence-informed and context-applicable strategies were used to enhance Prep-to-Play PRO implementation. These included collaborating with the AFL video production, graphic design and coaching advisory teams to produce branded, high-quality print and online coach and player education manuals, and technique videos. Final educational resources were uploaded to an AFL platform and printed hard copies were distributed to all club staff and players. In 2019, the AFLW Head of Women’s Football championed and endorsed the programme at pre-season club visits and through email communication to all staff. Clubs were offered training sessions and ongoing opportunities for AFLW programme implementers to discuss programme implementation with the research team during the 2019 season. At the end of 2019, all clubs received written or face-to-face club-specific feedback informed by survey, interview and direct observations. To support future maintenance, the research team and AFL developed a priority action plan, including dissemination to new AFLW clubs (from 10 to 14 teams in 2020). The research team also submitted a report to the AFL with implementation recommendations grouped under critical, important and ideal. Since the programme launched in 2019, the four new AFLW clubs that joined the competition were provided with Prep-to-Play PRO coach and player education manuals. The 2020 AFLW eight-game home-and-away season was interrupted by the COVID-19 pandemic. Some clubs forfeited games due to player COVID-19 cases, the season was cut short and no premiership was awarded. Therefore, we chose to re-evaluate programme implementation and maintenance after the next full AFLW season (2021). No AFLW-specific ongoing programme promotion or targeted implementation strategies have been undertaken since 2019.

Data collection and evaluation

Quantitative (survey) and qualitative (interviews, training observation, internal programme records) data were used to triangulate21 different stakeholder perspectives against the dimensions of the RE-AIM framework (table 1 and figure 1).15 Survey and interview questions focused on: (1) knowledge and implementation of Prep-to-Play PRO at their AFLW club; (2) the resources, support and strategies required to maximise future programme implementation; and (3) suggested programme improvements.

Research team members (MJH, AMB) extracted the evidence for each RE-AIM dimension into a RE-AIM scoresheet for each club (described below) unblinded to AFLW clubs (table 2).

Survey

Surveys were modified versions of previous injury prevention programme implementation evaluation surveys,21 and pilot-tested with five AFLW players and three staff members to improve readability and context specificity (online supplemental appendix 1). Participant demographics included age, years of AFLW and football experience, and history of ACL injuries and management. Staff were also asked about their AFLW role and experience working in elite sport (online supplemental appendix 1). The research team administered the 2019 player survey using Qualtrics (Qualtrics, Provo, Utah, USA) and it was disseminated electronically by club staff, members of the player leadership groups using club social media (eg, private Facebook group) and the AFL. The 2021 player survey was administered and distributed by the AFL Players’ Association. The 2019 staff survey was administered by the research team in Qualtrics and emailed to the club physiotherapist and high-performance manager with requests to forward to other staff involved in Prep-to-Play PRO implementation. Measures to increase response rate included: personal communication via email to all AFLW physiotherapists, at least one personal reminder to players from a member of the leadership group and at least one reminder from the AFL Players’ Association. All survey data were exported to Microsoft Excel, descriptive data (ie, mean, SD, proportions) calculated and extracted for each RE-AIM dimension by one researcher (MJH) and checked by a second (AMB). Descriptive statistics (means, SD, proportion, range) for player and staff responses were calculated in Microsoft Excel and SPSS (SPSS 2021 V.28, IBM Corp). Survey responses of ‘maybe’, ‘no’ and ‘no response’ were reduced to ‘no’.

Interviews

The study authors, who have clinical and research experience in sports injury prevention (AMB, KMC, ABM, AD, BEP), modified a previous interview guide21 aligned to the RE-AIM framework15 (online supplemental appendix 2). The interview guide was pilot tested with two AFLW players and two staff to check content relevance and understanding. The interview guide remained unchanged, and pilot data were included in the final analysis. All interviews (6 face-to-face, 26 Zoom) were audio-recorded and transcribed verbatim by a professional transcription service. A convenience sample of 19 current AFLW players and 13 staff responsible for injury prevention participated in individual semistructured interviews. To ensure maximum sample variation, 14 physiotherapists at each club identified potential athlete interviewees based on (1) football experience (eg, novice vs experienced), (2) occupation outside of football (eg, student, professional) and (3) perceived engagement in Prep-to-Play PRO. All athletes invited agreed to participate. Seventeen staff agreed to be interviewed. Selection was guided by role (ie, senior person responsible for injury prevention was invited first), club diversity (aimed for at least one staff member per club) and club implementation (partial vs high, informed by survey results). Interviews were mostly conducted by one female research team member (AMB, n=20), a musculoskeletal physiotherapist experienced in women’s Australian Football team context. Two female sports physiotherapists experienced in working with elite team sport athletes (SMC, n=6; ABM, n=3) and one male musculoskeletal physiotherapist (AGC, n=3) also conducted interviews. Multiple interviewers were involved to maximise participant recruitment and facilitate simultaneous data collection. All interviewers participated in regular meetings with the lead interviewer (AMB) to minimise differences in the quality of the interview interactions. All potential participants provided written informed consent before being interviewed. Interviewers had no prior relationship with the athletes, but two of the staff were known to the interviewer as they had previously participated in Prep-to-Play PRO development focus groups. On average, player and staff interview length was 30 minutes (range 18–43) and 44 minutes (range 22–56), respectively. We aimed to stop conducting interviews once data saturation (ie, no new ideas generated) was reached and there was sufficient diversity across participant roles and club implementation status. We took a conservative approach to deciding when saturation was reached (ie, we erred on the side of collecting more rather than less data) as data analysis was delayed because interviews were conducted concurrently or consecutively at clubs. Barriers and opportunities to idea saturation occurred after 16 interviews.

The qualitative study design was underpinned by an interpretive/constructivist epistemological approach looking to interpret the data from thick, rich descriptions. First, thematic analysis using a deductive, semantic approach against the RE-AIM framework25 was completed by one female clinician-scientist (MJH) trained by a senior researcher experienced in qualitative methods (AMB). We chose a researcher uninvolved in interview data collection to conduct the analysis to facilitate triangulation. Direct quotes from interviews that aligned to each RE-AIM dimension and item (interview question) were exported into club RE-AIM scoresheets by one researcher (MJH), before being coded and checked by a second (AMB). Barriers and opportunities (topic themes) for Prep-to-Play PRO implementation were thematically analysed using an inductive, semantic approach. AMB and MJH independently identified codes and subcategories from participant quotes of four transcripts (two staff, two players) and reached a consensus before MJH independently coded all remaining transcripts. During coding, MJH met with AMB and BEP to enhance credibility.

Observation of AFLW training

The nominated AFLW club contact (usually the team manager) for all clubs was contacted during 2019 pre-season to arrange for a research team member (AMB) to attend and observe a club training session. At a mutually convenient time, the researcher observed training to complete a standardised Prep-to-Play PRO observational recording sheet (online supplemental appendix 3).21 Evidence was extracted from each completed recording sheet on the RE-AIM dimensions of adoption and implementation by one researcher (MJH) and checked by a second (AMB).

Internal records of club Prep-to-Play PRO implementation

Over the 2019 AFLW season, the Prep-to-Play PRO project manager (AMB) maintained email records and notes from verbal communication and meetings with clubs and AFLW administrators about Prep-to-Play PRO reach, adoption and implementation.

RE-AIM scoresheet coding, scoring and analysis

The research team (AMB, AD, BEP, MJH) identified, collated and agreed on the available evidence from all data sources (player and staff interviews and surveys, internal records, direct observation) for each RE-AIM dimension (table 1). All data sources were used to complete a RE-AIM scoresheet21 for the original 10 AFLW clubs (ie, early implementers; table 2 and online supplemental appendix 4). Two independent assessors (AD, BEP), blinded to AFLW club, rated the evidence for each of the 58 items (figure 1). Each assessor then categorised each item as evidence of yes (ie, evidence supported achievement), evidence of no (ie, evidence supported non-achievement), no evidence (ie, no evidence to support or refute achievement) or unsure (ie, mix of evidence to support achievement and non-achievement). Discrepancies between assessors were resolved through discussion and further consideration of the available evidence with a third research member (AMB). Each assessor independently assigned an overall rating for each RE-AIM dimension: fully achieved (>50% of items evidence of yes, score=2), partially achieved (50% of items evidence of yes and 50% unsure or 50% mix of unsure and unanswered, score=1), not achieved (>50% items evidence of no, score=0) (online supplemental appendix 4). We took a pragmatic approach to rating the implementation dimension underpinned by an acknowledgement of sports injury prevention complexity.26 For example, if the evidence indicated teams intended to implement all five components but there were practical/operational reasons why all programme components were not implemented as intended at every training session or game, we assessed this as evidence of yes. Intended maintenance and actual maintenance were individually assessed and then combined to produce an overall maintenance rating and score (eg, intended maintenance fully achieved+actual maintenance fully achieved=maintenance fully achieved, intended maintenance fully achieved+actual maintenance partially achieved=maintenance partially achieved). A total RE-AIM score was calculated for each club out of 10, where 10 indicated higher Prep-to-Play PRO uptake. Prep-to-Play PRO reach and implementation for the four new 2021 AFLW clubs were assessed using six questions from the 2021 post-season survey.

Equality, diversity and inclusion statement

The current study aims to evaluate the implementation of Prep-to-Play PRO, a women’s and sport-specific injury prevention programme in the AFLW. The research team included diverse perspectives, including those of women and men, clinicians (physiotherapists) and clinician-scientists with a diversity of career stages (research assistance, PhD candidates through to professor) and members of the LGBTIQA+ community. We acknowledge the majority of authors are from one country and lack the perspectives of persons from middle to low-income countries.

Patient and public involvement

AFLW players and staff were involved in pilot testing interview guides, surveys and disseminating survey links to improve response rates. The 2021 player survey was administered and distributed by the AFL Players’ Association. AFLW players and staff were not involved in analysis or reporting.