Background

Recent systematic reviews highlight accumulating evidence for the efficacy of sports injury prevention interventions.1,–,4 These reviews often imply that such evidence is enough to ensure prevention of sports injuries through the uptake of these “proven” measures. Increasingly, however, newer studies are showing that when these interventions are implemented into real-world sports settings, rather than just contrived laboratory settings, they are not effective because they are not used by the target group in the way that was intended. Systematic reviews often only collate evidence from randomised controlled trials (RCTS) that purport to assess the effectiveness of interventions because they use widely advocated intention-totreat analysis approaches. However, these RCTs are, by definition, still highly controlled and do not accurately reflect the final implementation context for the intervention, even if they give considerable attention to issues of compliance and adherence to the preventive measure under evaluation. There is a very real need to evaluate the effectiveness of sports safety interventions in the real-world context of sports delivery under natural and uncontrolled conditions, even if their efficacy has already been demonstrated (in RCTs). If efficacious interventions are not widely adopted, complied with and sustained as ongoing practice, then it is very unlikely that any significant public health impact will be made.

In 2006, Finch outlined the Translating Research into Injury Prevention Practice (TRIPP) framework (Box 1) and argued that “future advances in sports injury prevention will only be achieved if research efforts are directed towards understanding the implementation context for injury prevention, as well as continuing to build the evidence-base for their efficacy and effectiveness of interventions.”5 Stages 5 and 6 of the TRIPP model are particularly important for injury prevention because understanding the barriers and facilitators to the widespread adoption and sustainability of prevention measures is vital to identifying targets for specific implementation efforts.

Undoubtedly, it is critical that all implemented sports safety interventions have a strong evidence base. However, it is equally important that they are also effective and are able to be readily taken up in the “real world”, as only those preventive measures that are adopted as standard sporting practice will actually prevent injuries.5 For example, in a field-based RCT of the effectiveness of headgear and mouthguards in Australian football participants, very few participants wore the headgear,6 7 indicating that the best designed protective equipment cannot prevent injuries if participants do not use it. Another Australian football study found that the latest scientific evidence about exercises for lower limb injury prevention was not yet being incorporated into coaches' beliefs and specific practices when delivering training programmes for players.8 Considered together, these studies highlight a major gap in injury prevention implementation, suggesting that more research is needed in this area.

The issue is not restricted to coaches and participants. Peak sports body consultations have confirmed that, to progress safety, they need clear guidelines that translate the scientific evidence into practical tools and approaches that they can adopt at a local level.9 Despite the availability of evidencebased interventions, it is clear that sports injury prevention efforts are currently hampered by a limited understanding of their implementation context. This issue has been recognised as an international challenge for the field.5 10 11

Progressing research innovation in this direction will require a major paradigm shift. In particular, it requires the integration of social science methods with the more usual sports medicine and population health perspectives. One way to move forward would be to use existing health promotion frameworks to inform injury prevention research efforts. This will help in better understanding the complexities of implementation contexts and provide cues to improving study/evaluation designs and conducting research into understanding implementation processes.

This paper suggests a way forward for the design of real-world implementation evaluation studies in the community sport setting to ensure that the full complexities of the sports delivery context are considered from the outset. It draws on the RE-AIM health promotion evaluation framework of Glasgow and colleagues6 7 12 13 to understand how and where to best implement multifaceted interventions. An extension of the “standard” RE-AIM framework is presented to enhance its relevance to the “real-world” delivery context of community sport.

The RE-AIM framework

Glasgow at al's RE-AIM framework12 13 has five key dimensions for assessing interventions in the implementation context:

Reach — the proportion of the target population that participated in the intervention

Effectiveness — the success rate if implemented as intended, defined as positive outcomes minus negative outcomes

Adoption — the proportion of people, settings, practices and plans that adopt the intervention

Implementation — the extent to which the intervention is implemented as intended in the real world

Maintenance — the extent to which the intervention is sustained over time. This aspect is often categorised according to individual-level and setting-level maintenance.

A framework such as RE-AIM is useful for evaluating the public health impact of sports injury prevention interventions because it provides cues on how to think about the full complexities of the implementation context.

The RE-AIM framework has been applied to a Tai Chi program for elderly falls prevention,14 lifestyle interventions targeting cardiovascular disease risk factors,15 exercise programmes for people with arthritis16 and community-based behavioural interventions.17 In the sporting context, such a framework could be applied to injury prevention initiatives directed at individual sports participants, such as individual behaviour change (eg taping ankles or wearing protective equipment). It could equally be applied to interventions delivered by a coach to a whole team of participants (eg exercise training programmes) or higher-order interventions delivered by sports governing bodies (eg safety regulations).

To date, almost all publications describing applications of the RE-AIM framework have focused on interventions for achieving individual (person-focused) behaviour change that are delivered by professionals in a specified setting. In these applications, the reach, effectiveness and maintenance dimensions have been assessed in terms of individual outcomes, while the adoption, implementation and maintenance dimensions have assessed settings-related factors.17 For example, the only injury prevention-related study in which the RE-AIM framework has been applied to date involved a Tai Chi group exercise programme delivered through community health services to prevent falls in community-dwelling older people.14 The reach of the programme was assessed in terms of the number of eligible people; the number of people who participated; and the representativeness of the target population. Effectiveness was assessed as individual participant changes in measure of physical performance; changes in measures of quality of life; and frequency of falls. At the setting level (ie community centre), adoption was measured as the percentage of local community centres that agreed to participate and the percentage of local community centres that implemented the programme. Implementation was measured as adherence to the implementation plan provided; maintenance of a 2 week programme schedule; attainment of attendance >74% over 12 weeks; and documentation of ≥30 min in-home practice per week. Within the community health centres, maintenance was determined through centres' willingness to consider Tai Chi as part of future programmes and the likelihood of continuation of the programme after completion of the intervention. For the older people who participated in the programme, maintenance was assessed as the number of participants continuing Tai Chi practice 12 weeks after the classes had finished.

An extended RE-AIM matrix for interventions delivered through community sport

Care needs to be taken when directly applying the RE-AIM framework to interventions implemented in the community sport setting because the definition for each dimension will depend on the specific level being targeted. Whilst some interventions will be targeted at only one level (usually the individual athlete), most sports injury interventions are multifaceted and complex18,–,20 and therefore need to be targeted at multiple levels. Using the RE-AIM framework will therefore also require that each dimension is assessed at multiple levels. Given the multilevel, hierarchical delivery of community sport, it is necessary to extend the “standard” RE-AIM framework to accommodate the delivery-setting complexity and optimise intervention delivery and evaluation.

In many regions, grass-roots sport is delivered through a network of community sports clubs. Behind this network, organised sport is generally administered in a hierarchical manner within an international, national, state/provincial and regional structure. The responsibility for safety differs according to where in the overarching administrative hierarchy the organisation actually delivering the intervention sits. For example, in Australia, National Sporting Organisations (NSOs), such as Football Federation Australia, Cricket Australia or Tennis Australia, are at the top of the administrative hierarchy. These organisations are often affiliated with international sports bodies and are responsible for ensuring that international rules, policies and standards are applied throughout the country. The NSOs provide strategic, policy and operational guidance to State Sporting Organisations (SSOs), which, in turn, are responsible for delivering these aspects to sub-international sport within each state or territory of Australia. The SSOs do this by directly coordinating national elite or professional sport competitions and by overseeing regional sports body activities. The SSOs, at least for the major sports, usually have minimal direct contact with the delivery of community sport, though they are often responsible for coach and referee/umpire accreditation and training, as well as insurance coverage for all involved. The SSOs may also prepare safety guidelines and other resources for distribution to community sport.21 Information and responsibility often flows through the regional sports bodies, which have direct responsibility for the clubs within their region and for factors such as sports delivery policy and links with sports facility providers.

Within particular clubs, there are often multiple sporting teams and levels of play (eg masters/veterans, seniors, juniors, men or boys, women or girls, beginners/precompetition, etc). Grass-roots injury prevention implementation is generally delivered through individual teams, with the coach as the major delivery agent. Local safety policies and practices are usually set at the club level in response to regional or state directives.21,–,25 Most sports participants only have direct interaction with the team of which they are members and/or their coach.

There have been very few international studies to quantify the extent to which safety policy and practice occurs at each level within the administrative hierarchy. However, our previous work21,–,26 has consistently shown that:

• ▶. the injury risk management strategies and processes at the lower levels (eg community clubs) are often driven by those at higher levels (eg NSOs, SSOs) of the sports delivery hierarchy;

• ▶. despite this, action or policy at a higher level does not always lead to implementation of relevant practice at a lower level; and

• ▶. there is often a discrepancy between what sports bodies, at any level, report they do and what is regularly implemented as ongoing practice in community clubs.

Therefore, when introducing a new sports safety or health promotion initiative, its uptake and effectiveness should be evaluated across all relevant tiers of influence. This requires an extension to the standard RE-AIM framework.

The matrix (RE-AIM Sports Setting Matrix (RE-AIM SSM)) presented in table 1 is a novel extension of the RE-AIM framework, identifying where each of its dimensions could be assessed across the sports delivery hierarchy. At a national, state and regional level, initiatives could be evaluated in terms of: commitment; communication strategies; education and training provided; finance and other resources allocated; formalising of safety committee structures and monitoring processes; policies; documented decision processes; and attitudes/knowledge of key personnel, etc.

At the club level, factors for consideration include: organisational infrastructure; policy development/implementation/monitoring; training/support for coaches; sports administrative support/monitoring; promotion and communication; and attitudes/knowledge of club officials and key administrators. Within teams, the following factors become important: implementation of training guidelines; coach plans/practices and attitudes/knowledge; documentation; accountability to club; and communication strategies.

Finally, the end goal of most safety interventions is to make the game safer for individual participants. At this level, key evaluation outcomes could include: the proportion (and number) of participants exposed to the intervention; participant awareness/knowledge of interventions; proportion of participants incorporating the intervention into routine activity; and rates of relevant injuries (eg per 1000 participant exposures).

Table 1 also highlights that, for many sports safety interventions intended to generate a public health impact, the sports delivery setting-related factors will probably be at least as important as, and more numerous than, those directly related to the individual sports participants.

Lower limb exercise training programmes as an example

One of the injury prevention interventions currently receiving considerable attention in the international literature across a range of sports is specially designed exercise training programmes to prevent lower limb injuries. Such injuries are common in many sports and there is very strong evidence that they can be prevented through targeted training incorporating structured warm-up, balance training, side-stepping/cutting skills and jump/landing training.27,–,31 These programmes are often delivered by coaches at a team level, with the specific aim of preventing lower limb injuries in team members. Findings from a 2 year prospective cohort study that participants who have participated in preseason training programmes or received specialist coaching are significantly less likely to be injured than other participants32 add weight to the value of such exercise training programmes as a sports safety measure.

Most of the evidence supporting the exercise training programmes comes from well-designed, highly controlled RCTs and/or laboratory-based biomechanically focused studies.27,–,31 However, as results from more “real-world” (ie club/team-based) implementation studies have started to become available, there is concern that these programmes have shown limited success in actually preventing injuries. This has been attributed to a low compliance with the programmes by the targeted participants, a lack of relevance to real-world community sport and poor transferability across implementation contexts.33 The impact of “non-compliance” with interventions on injury reductions has also been highlighted in other RCTs of lower limb injury prevention measures in soccer.34,–,36 Taken together, this further emphasises the need for more information generated from appropriate and well-designed research studies aimed at fully understanding the implementation context, as outlined in the TRIPP framework of Box 1.5

To illustrate how the RE-AIM SSM could be used, consider its application to an intervention requiring coaches to deliver an evidence-based exercise training programme to participants during regular training sessions to reduce the risk of lower limb injury in these players. Whilst the individuals undertaking the exercises during training sessions receive the benefit, successful implementation of the intervention relies heavily on the structures and background activities in place to support delivery of the training programme. The coaches themselves need to receive formal training in the components of the programme, including the rationale for both prevention and performance benefits, and how to deliver it optimally to ensure high participant compliance/uptake. The coaches also need to build the programme into their regular training sessions and ensure it is delivered in the way it was intended. To facilitate this, regional associations/leagues and even state sporting organisations need to develop an overall programme that is evidencebased and targeted for the specific sport, and which provides formal training opportunities for the coaches. This is likely to require the development and dissemination of resources and other programme support materials that are regularly reviewed and updated. In some cases, this may also require either national or state sporting organisation endorsement. From an individual point of view, participants need to attend training, participate in the coach-led exercise training programme and integrate the programme into their ongoing individual training and participation habits.

Table 2 gives some examples of how the RE-AIM SSM could be used to guide the evaluation of the implementation and evaluation of a coach-led lower limb injury prevention exercise training programme in a community sports setting. The implementation measurements listed are indicative of the range of factors that should be considered, rather than being exhaustive, when designing implementation studies and developing evaluation tools.

Concluding remarks and research directions

To progress the sports injury prevention field, researchers need to think more broadly about its directions. Whilst it is important to continue to build a strong efficacy evidence base of the prevention measures or strategies we want to implement, it is also critical that researchers better understand implementation issues and develop appropriate strategies to implement and evaluate interventions in “real-world” settings. Conducting RCTs using intention-to-treat analyses to measure the “effectiveness” of interventions is not the same as conducting an implementation study which considers the impact of an intervention in a realworld, uncontrolled setting. Unfortunately, there are very few examples of such implementation studies in sports injury prevention, or in injury prevention more broadly, even though the need for such studies is well recognised.37 38

During intervention planning, sports injury researchers need to begin to consider more than just the efficacy of the intervention. They should also ask questions about the implementation context, such as: what are actual behaviours? are attitudes and knowledge favourable? what would make people/communities more or less likely to adopt it? what setting/cultural delivery factors are also important? what infrastructure support is needed in the setting? To help answer such questions in the best way, the sports injury research field will need to develop new recording and reporting approaches. The RE-AIM SSM presented in this paper provides a first step in understanding how various complexities of the implementation context could be considered.

Effective sports injury prevention requires successful implementation of efficacious interventions.5 This, in turn, requires knowledge about the implementation context, including how people (their attitudes and safety (or risk) behaviours etc) interact with interventions and how interventions can be changed without adverse effects.11 Moreover, researchers need to know more about the factors that influence the sustainability of interventions to ensure significant injury prevention benefits are continued well after the evaluation research is completed and its accompanying funding and resourcing withdrawn. Such factors are more likely to be related to the settings in which the interventions are applied, rather than to personal athlete factors, but there is a general lack of published studies on this aspect in the peer-reviewed literature.

To progress full understanding of how to implement highly effective interventions in the context of real-world sport delivery, there is a need to develop new, or modify existing, implementation models and research approaches to meet the specific needs of sports safety intervention research in sports settings. This will require active collaboration of sports medicine researchers with qualitative researchers and health promotion professionals who have expertise and experience in the evaluation of implemented health and safety programmes. There may also be a need to inform funding agencies and journal editors of the importance of effectiveness research, as well as controlled efficacy trials.

This paper provides a novel extension of the health promotion RE-AIM evaluation framework, which is specific to the contexts in which sport is delivered in the “real world” and can guide future work in this area. The authors plan to use this over the next few years to assess its fidelity and use as an ongoing evaluation design tool for community-based sports safety initiatives.

Finally, although developed in the context of community sports safety, the sports setting matrix presented in this paper has wider implications for other health promotion interventions delivered through community sport settings, such as sun protection, healthy eating and responsible alcohol consumption.39 40