If we build it together, will they use it? A mixed-methods study evaluating the implementation of Prep-to-Play PRO: an injury prevention programme for women’s elite Australian Football

Objectives We evaluated the implementation of Prep-to-Play PRO, an injury prevention programme for women’s elite Australian Football League (AFLW). Methods The Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) of Prep-to-Play PRO were assessed based on the proportion of AFLW players and/or staff who: were aware of the programme (R), believed it may reduce anterior cruciate ligament injury (E), attempted to implement any/all programme components (A), implemented all intended components as practically as possible (I) and intended future programme implementation (M). Quantitative and qualitative data were triangulated to assess 58 RE-AIM items (evidence of yes/no/unsure/no evidence) and the 5 RE-AIM dimensions (fully achieved=evidence of yes on >50% dimension items, partially achieved=50% of items evidence of yes and 50% unsure or 50% mix of unsure and unanswered, or not met=evidence of yes on <50% dimension items). Results Multiple sources including AFLW training observations (n=7 total), post-implementation surveys (141 players, 25 staff), semistructured interviews (19 players, 13 staff) and internal programme records (9 staff) contributed to the RE-AIM assessment. After the 2019 season, 8 of 10 (80%) AFLW clubs fully met all five RE-AIM dimensions. All 10 clubs participating in the AFLW fully achieved the reach (R) dimension. One club partially achieved the implementation (I) dimension, and one club partially achieved the effectiveness (E) and adoption (A) dimensions. Conclusion The Prep-to-Play PRO injury prevention programme for the AFLW achieved high implementation, possibly due to the programme’s deliberately flexible approach coupled with our pragmatic definition of implementation. Engaging key stakeholders at multiple ecological levels (organisation, coaches, athletes) throughout programme development and implementation likely enhanced programme implementation.

If we build it together, will they use it?A mixedmethods study evaluating the implementation of Prep-to-Play PRO: an injury prevention programme for women's elite Australian Football

INTRODUCTION
2][3] Efficacious injury prevention programmes can reduce ACL injuries by up to 67%, 4 5 yet implementation challenges exist (eg, as low as 20% in girls soccer). 6Strategies such as coach education and programme integration into pre-existing warm-ups 7 have failed to improve high-fidelity implementation in the real-world sport setting. 8ne solution could be partnering with key stakeholders from the outset to co-create injury prevention programmes and implementation strategies.If this approach to injury prevention programme design and implementation planning is associated

WHAT IS ALREADY KNOWN ON THIS TOPIC
⇒ Women have two to eight times greater risk of anterior cruciate ligament (ACL) injuries than men.⇒ Efficacious injury prevention programmes can reduce ACL injuries, yet implementation is usually low.⇒ Partnering with stakeholders from the outset may lead to higher injury prevention programme implementation.⇒ Sustained implementation is rarely evaluated.

WHAT THIS STUDY ADDS
⇒ Involving the sport organisation, players and a range of staff at the beginning of Prep-to-Play PRO programme design and implementation planning was associated with high programme uptake in the women's elite Australian Football League.⇒ Ongoing stakeholder input and injury prevention programme resourcing is needed to ensure sustained programme implementation.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
⇒ Long-term programme adaptation and implementation planning is needed to ensure programmes remain relevant and meet everchanging sporting context needs.⇒ Future studies should evaluate stakeholders' perspectives and practices across policy, community and organisational levels of the socioecological model to uncover further opportunities to enhance programme implementation.

Original research
with programme use, it may help to curb the growing rate of ACL injuries and healthcare costs. 9][14] In the absence of an injury prevention programme specifically designed for women playing elite Australian Football, with the knowledge that programme implementation is complex and multifactorial, a comprehensive approach to programme design and implementation planning was undertaken.The Prep-to-Play PRO programme and implementation plan were created in partnership with stakeholders across multiple ecological levels (eg, governing sport, coaches, players) to enhance implementation. 2 10Evaluation frameworks such as Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) 15 allow us to understand if co-creating injury prevention programmes and implementation plans can result in programme uptake in real-world settings.Sustained programme implementation is rarely evaluated, 16 with systematic reviews reporting maintenance between 1% 17 and 13% 18 in team ball sport and rugby, respectively.No evidence of sustained maintenance exists in elite sports settings. 17 18The AFLW context provides a unique opportunity to explore and extend our knowledge of injury prevention programme implementation and maintenance in elite sport.
With women at an unacceptably high risk of ACL injury compared with men, 19 ongoing burden 20 and subsequent ACL injury, 14 the high-fidelity and sustained implementation of effective injury prevention programmes is critical to minimise ACL injury risk.This study aims to evaluate the implementation and maintenance of Prep-to-Play PRO in the elite AFLW.

METHODS
The mixed-methods parallel study design 21 was guided by the RE-AIM sport setting matrix (SSM) 22 to evaluate Prep-to-Play PRO implementation at the end of the 2019 AFLW season, and maintenance in 2021.RE-AIM SSM incorporates the original five key RE-AIM dimensions operating across many levels of the sports delivery system (organisation, team, player) to enhance programme translation in team ball sports. 17Our evaluation concentrated on the team (including the medical and performance support professionals) and player level (table 1).The manuscript has been checked against the Standards for Reporting Implementation Studies and CHecklist for statistical Assessment of Medical Papers checklists. 23 24

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.

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

Original research
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 11rogramme and implementation strategy development have been reported in detail. 11Briefly, 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 clubspecific 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-andaway 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 triangulate 21 different stakeholder perspectives against the dimensions of the RE-AIM framework (table 1 and figure 1). 15Survey 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 pilottested 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 guide 21 aligned to the RE-AIM framework 15 (online supplemental appendix 2).The interview  'Yes most definitely.If they've got a reduction in injury risk for one, they can train more and are not hampered by injury but then two, their movement skills or their movement pattern in particular definitely has improved their performance.They are understanding body position for them from a skills and technical and tactical coaching point of view is an important one because that is something that they have not been taught probably ever as well.So, just understanding how to move and how to be in the right position to protect themselves and the ball has been a big change for them which is good.'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.

Evidence of yes
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 framework 25 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). 21Evidence 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

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 scoresheet 21 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. 26For 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 Prepto-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.

RESULTS
One hundred and sixty-six AFLW players and staff representing all 10 clubs participated in the 2019 post-season survey (response rate ~47%) (table 3 and figure 1).Data points varied for each club-ranging from 75 to 599 per club (median 362)depending on the number of players and staff recruited.After the 2019 AFLW season, 8 out of 10 AFLW clubs fully achieved all five RE-AIM dimensions, indicating high Prep-to-Play PRO uptake (table 4).All 10 clubs fully achieved the reach dimension.One club partially achieved the implementation dimension (conflicting evidence of programme implementation as intended) but fully achieved all other dimensions.One club partially achieved the perceived effectiveness and adoption dimensions and subsequently did not implement or maintain the programme.An example of the scoring sheet for one club can be found in online supplemental appendix 3.At the end of the 2021 AFLW season, all 14 clubs, including the 4 new clubs, fully achieved the reach dimension.Of the 10 original clubs, 7 continued to implement Prep-to-Play PRO as intended.Two of the early implementers and two of the new clubs partially implemented the programme during 2021.One new club fully achieved the implementation dimension, and one was rated as no achievement.Examples of evidence for each data source and evidence rating are in table 2.
Player and coach survey responses were similar for each RE-AIM dimension (table 5).Player and staff interview participants identified barriers and opportunities for education, Table 3 Sociodemographic details for 2019 survey and interview participants

Original research
programme structure, culture and professionalism (table 6 and online supplemental appendix 5).

DISCUSSION
It has been suggested that about 14% of the best scientific evidence will be adopted, and it will take 17 years until it is used in the real world. 27Our study highlights that it is possible to achieve real-world implementation in much faster time frames.Our deliberate organisation and research partnership including an AFLW player (BEP) and a staff member (MJH), groundwork to understand AFLW player perspectives on injury prevention, 2 programme co-creation with content and context experts 10 and implementation co-design, 11 is likely to have led to the fast implementation rate.We have high confidence that during the 2019 AFLW season, most players and staff knew about Prepto-Play PRO, 90% of AFLW clubs adopted it and 80% of clubs implemented it as it was intended (all components, dosage, frequency, in/out of season) as practically as possible within contextual and environmental constraints (table 4).Of the early implementers, 70% of players reported that Prep-to-Play PRO was implemented as intended 2 years later (table 4).Our mixedmethods design across multiple ecological levels in women's elite sport has revealed that we can increase the speed of research to practice translation.Many efficacious exercise-based injury prevention programmes exist, yet implementation is typically low.Our 90% adoption and 80% implementation rates are in stark contrast to the 6-30% implementation rates of exercise-based injury prevention programmes in women's elite handball, 28 men's professional European football and cricket, 29 30 and community female youth soccer. 6The differences may partly be explained by (but not limited to) programme perception, 29 adaptability, 31 time required to implement, 28 or strategies to improve deliverer knowledge and capability. 6At the time of evaluation, the AFLW was a 14-club elite league, representing a smaller and possibly more homogeneous cohort compared with nationwide community sport.The varying implementation rates may also reflect the different sport sizes and context-related challenges between elite, subelite and community sport.
High programme implementation may be achieved through tailored solutions.Built with end-users, Prep-to-Play PRO was created specifically for the elite AFLW in partnership with stakeholders across multiple socioecological levels of the AFLW system. 10 11The partnership began with a meeting between the research team (including BEP, an AFLW player at the time) and the AFL head and safety officer to discuss the ACL injury problem.The high ACL injury risk and lack of prevention programme awareness among AFL, AFLW staff and players likely indicated a readiness for change and subsequent 'permission to implement'. 32rom the beginning, the AFL (sporting organisation) prioritised the need to reduce ACL injuries, and financially and administratively invested in a co-created solution with stakeholders.Most published injury prevention programmes were developed by researchers and/or clinicians with minimal reports of end-user engagement during programme design and planning phases, 33 34 which may partly explain low programme relevance and uptake.Programme design and implementation planning with people who understand the unique sport, organisation, team and player demands is consistent with recent reviews, 26 studies 16 35 and opinions. 36Prep-to-Play PRO was designed around five key components, providing autonomy for exercise selection and programme flexibility to capitalise on AFLW staff injury prevention knowledge and skills in the elite setting.Almost all injury prevention club personnel involved in this study held a higher education degree in a relevant field (eg, sport science, physiotherapy), and over half had worked with other elite sports (table 3).Allowing staff exercise selection autonomy (ie, creating their own) may have led to high implementation: a more sustainable solution. 36he high level of knowledge and skills among AFLW staff is unlikely to be replicated in other sport settings, such as community Australian Football, pointing to different environmental needs.Community-level coaches' knowledge and skill diversity may require injury prevention programmes to be more generic and easily delivered (ie, prescriptive, easy to follow), with regular coach education opportunities critical to enhancing uptake. 37s more sport injury prevention programmes use participatory action methods to address implementation barriers, 35 we may achieve consistently higher implementation rates.

research
Our pragmatic RE-AIM definitions may have inflated the assessed Prep-to-Play PRO uptake.We did not prospectively assess specific measures of adherence (eg, utilisation frequency) and exercise fidelity typically used in injury prevention clinical trials, 38 which are easier to evaluate than a principle-driven programme like Prep-to-Play PRO.Better understanding of the critical ingredients for injury prevention programmes can inform future implementation evaluations, along with reliable and efficient options to measure implementation (eg, coach, player or team designate self-report compared with independent observer).
Maintenance of programme implementation is rarely evaluated. 17Despite all good intentions to maintain Prep-to-Play PRO implementation by all early implementers, self-reported maintenance at 2 years dropped by 22%.Time, resources and access to staff were barriers to Prep-to-Play PRO implementation and maintenance, likely reflecting the semiprofessional nature, and competing personal, work and study demands of players and staff.Lack of ongoing stakeholder input after initial design and implementation may also partly explain reduced Prep-to-Play PRO maintenance. 39Sport-governing bodies need to support coaches and other programme deliverers throughout the entire implementation and maintenance process. 40Targeted solutions are needed to educate and support sustained programme adoption and implementation among new coaches, deliverers and athletes.Stakeholder partnership is a great place to start, but staff turnover may lead to the people originally involved no longer being in place, and presents the problem of engaging new staff and getting their investment.Injury prevention programmes must be embedded within organisations that take responsibility to own and continuously resource them.The AFL is an example of an organisation that has a long-term commitment and investment plan to reducing ACL injuries at all levels of women's football.Players and staff suggested that Prep-to-Play PRO needs to be more prescriptive, easier to use, with more support and training for less experienced coaches in community-level sport.These suggestions speak to the need to create context-specific programmes with improved content. 36Responding to this feedback, Prep-to-Play PRO was modified in partnership with key stakeholders specific to women's community Australian Football, 41 and is now freely available to all coaches, and being tested in a randomised clinical trial. 42Responses of 4 (somewhat effective) and 5 (very effective) were converted to 'yes'.
Responses of 1 (very ineffective) to 3 (unsure) were converted to 'no'.†made up of 5 questions where 'yes' was recorded if (1) Individual preparation -every session and game, and (2) Movement skills -every session and game, including jump and land, deceleration, change of direction, and (3) Football-specific skills -every session and game, including contact skills/tackling/ground balls, and (4) Strength & conditioning -all muscle groups supervised at least twice per week, and (5) Education (general performance enhancers and injury reduction principles) -weekly.ACL, anterior cruciate ligament injures; AFLW, Australian Football League for Women.

Table 1
The Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) dimensions and definitions specific to this project and data sources

Dimension, total number of items, definition Timeline, data source, number of items 2019 in-season 2019 post-season 2021 post- season Direct observations* Internal records Survey † Interviews ‡ Survey † Reach (R) 10 items AFLW
team personnel responsible for ACL injury prevention or AFLW players who were aware of Prepto-Play PRO at the end of the 2019 AFLW season.Maintenance (M) 6 items (5 intended M, 1 actual M)Intended M: AFLW teams that intended to use Prep-to-Play PRO in future seasons (2019 evaluation) ACL, anterior cruciate ligament; AFLW, Australian Football League for Women.

Table 2
Examples of different sources of evidence for each Reach, Effectiveness, Adoption, Implementation and Maintenance dimension and rating

Source (club), item detail Evidence example (n, proportion of respondents) Rating Reach (R) (10 items, 10 potential sources)
'Yeah, it would've been effective in reducing an ACL injury.I think.I feel stronger, especially in my glutes.VMO (Vastus Medialis Oblique) has made it a little bit harder to feel that initially unless you are actually activating it, but when I feel strong in my glutes I feel less prone to any injury, let alone, just a knee injury.' 'I ran an education session with the playing group last Friday night & went through the Prep-to-Play PowerPoint presentation.'Evidence of yes R Player interview (club C) Have you seen the player education manual?'Yes' (Player 1); 'I think I have' (Player 2); 'Yes, they handed it to us at training' (Player 3); (n=3, 100%)

) (22 items, 22 potential sources)
Otherwise, programmes need to be completed in full at end of training.6 min of group activation/mobility commences with physical preparation coordinator (rehabilitation) after team meeting that includes band exs for activation, bridges, hip rotators, crab walk all directions and sumo squats.Technique cues only.Performed indoors.Movement skills: performed on group.Progression through increasing difficulty of exercises/drills.General group technique cues provided.Video recording of some run throughs for analysis of technique later.Physical preparation coordination supervised by coaches.Duration=12 min, followed by 6 min running conditioning.Drills included: alternating squats, high knee skip, rhythm A skip, leg swings, deceleration, single leg land after contact, reactive (auditory) cues, deceleration, change of direction 80-85% run throughs, followed by 6 min of run throughs (including bounding) and then 3 min contact work in pairs.Two players arrived onto field late, coaches took them aside to work them progressively through warm-up.Also incorporated into first 15 min of training (skill acquisition phase).Sport-specific: 5 min for ground balls-not individualised.Progressed through introducing balls, opponents.General technique feedback and cueing.Strength and conditioning: weights at end of training.Running drills after on-field warm-up.Weights-individual programmes.Running as group: 30-40 min.2 staff available.Each player has an individual programme but in groups of players.Players were separated into 4 groups at the beginning of the season ranging from novice lifters to advanced.Novice lifters had extra supervision and technique correction particularly in the early part of pre-season.
Adoption (A) (8 items, 12 potential sources)* A Internal programme records: email communication (staff 19 Dec 2018, club C) 'The high performance and medical team have worked very closely in integrating the program into our warm up sessions and a lot have overlapped with other drills we already had set out.At our induction day and again at our pre season camp, we discussed with all players and staff the importance of this program -to be adherent to it as well as not reducing time spent on the program with the given training time restraints set for each session/week.'Evidence of yes A Direct observation of AFLW training session (13 Mar 2019, club G) Individual preparation: players circulated through the gym anytime from 16:00.No staff were present.Players took ownership for the exercises they were doing.Approximately 15 players at different times from around 16:30 completed individual preparation exercises which included hip activation, crab walks with bands in all directions, isometric hamstrings, foam rolling, mobility and stretching.Movement skills were completed on ground.Sport-specific skills completed as part of normal training.Strength and conditioning occurred at end of training.'Yeah, it would have been done by a range of staff at the club, it wouldn't have just been done by one of us.' Evidence of yes Implementation (ISummary of observation: Individual preparation: about 8-10 players performing part of weight training, for example, upper body, plyometric. 2 staff were present.Players were taking ownership for their preparation but spoke to staff for clarification of exercises/technique, etc. Observed plyometric box jumps (supervised by high-performance staff) for 'soft landings'.Players unrestricted by work commitments and can arrive early take advantage of this.I Player survey (club G) Did you receive a formal face-to-face education sessions about Prep-to-Play PRO? Yes (n=4, 16%); unsure (n=9, 37%); no (n=10, 42%); unanswered (n=1, 4%) Unsure I Player survey (club A) In an average week, how many times did you complete strength and conditioning training under supervision?Twice a week or more (n=4, 50%); less than twice a week (n=3, 37.5%); unanswered (n=1, 12.5%) Evidence of no Continued Original research 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 audiorecorded 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.

Table 5
Player and staff survey responses to Prep-to-Play PRO Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) *effectiveness was measured on a Likert scale 1 (very ineffective) to 5 (very effective).

Table 6
Barriers and opportunities to Prep-to-Play PRO implementation

Theme 1: Barriers to Prep-to-Play PRO implementation
Across all leagues and levels -from grassroots to the sub-elite AFLW, Australian Football League for Women.;