Introduction
The Rugby Football Union (RFU), England’s rugby union governing body, has been championing the Activate injury prevention exercise programme. The 20 min warm-up, designed to be completed prior to training and matches, has shown to be efficacious in reducing youth rugby injury risk.1 There are three age group-specific programme available, under-15/16/18, incorporating balance, resistance and plyometric exercises with four progressive phases to be completed throughout the season.1 2 In a randomised controlled trial of English schoolboy rugby (under-15 to under-18 years old), a 72% reduction in overall match injuries and a 59% reduction in concussions were reported in teams maintaining full compliance through a season (≥3 times per week). However, only 16% of teams in the intervention arm completed Activate as prescribed. If highly resourced schools, supported by a research team, could not maintain compliance over a single season, it raises questions regarding Activate’s longer-term effectiveness given the complexity of implementing such interventions in broader sporting contexts.3 4
Injury prevention programmes across various sports have been impacted by poor implementation.5–7 The 11+ (previously FIFA 11+) is perhaps the most widely evaluated programme, with meta-analyses revealing a 20%–70% reduction in injury rates across various settings.8–10 However, in 2015, only 10% of national football associations endorsed the programme.11 Low end-user awareness and adoption have been reported worldwide,12–14 highlighting the difficulty in successfully disseminating and implementing such interventions.4 Numerous contextual complexities influence the transfer of findings from research to practice, including individual perceptions, social influences, political pressures and physical demands.15–17 Many of these factors are not evaluated in research or addressed in practice, possibly due to the misconception that people will automatically adopt efficacious interventions because injury prevention is of high priority.18 19
Evaluating influences on end-user behaviour is a critical step towards successful implementation.3 This is particularly important in community-based environments where users may be volunteers, lack adequate training or are constrained by time and resources.20 One tool used to evaluate the implementation of public health interventions is the reach, effectiveness, adoption, implementation and maintenance (RE-AIM) framework.21 Briefly, the framework assesses an intervention through five dimensions (table 1); reach (R), effectiveness (E), adoption (A), implementation (I) and maintenance (M), with barriers and facilitators occurring at each dimension. Sport-specific modifications have been recommended to the original framework,22 including evaluating each dimension at different hierarchical levels (eg, coaches and players) because differences in knowledge, perceptions and contextual factors at different levels can influence intervention implementation. This was highlighted in a population of South African schoolboy rugby coaches and players, where awareness and knowledge of the BokSmart injury prevention programme significantly differed between these two groups.23 RE-AIM suggests that for interventions to have their desired impact, they need to be well known, adopted and implemented over prolonged periods. This is relevant for sports injury prevention programmes,1 24 yet research heavily focuses on effectiveness with little assessment of the remaining dimensions.25 26 Only efficacy has been assessed for Activate in school rugby.1
End-user perceptions influence injury prevention behaviours,3 thus evaluating these in school rugby coaches, support staff and players would provide valuable information to aid Activate implementation. Therefore, this study’s objectives were to (1) describe and compare baseline knowledge and perceptions of rugby union coaches (including support staff) and players towards injury risk, injury prevention and Activate and (2) evaluate Activate’s ‘reach’, ‘adoption’, ‘effectiveness’, ‘implementation’ and ‘maintenance’ in English schoolboy rugby.