Clearly and properly reported findings concerning the implementation of effective sports injury intervention programmes are scarce.19 20 This study contributes to narrowing this science practice gap. Questionnaires, interviews and online analytics generated valuable information on how implementation strategies implementing WUP were deployed and how WUP was evaluated. The implementation of WUP did not exactly go as planned due to a delayed start of the implementation and the COVID-19 outbreak. Implementation strategies were effective in attracting new WUP users, although should be refined to stimulate adherence. Future integration of WUP in existing KNHB platforms might help to stimulate adherence. Nevertheless, WUP users were satisfied with the intervention programme.
WUP evaluation and its implementation in compliance with RE-AIM
Regarding reach, an estimation could be provided of the percentage of trainers/coaches who registered for WUP, namely 7%. During the study period, reach may be influenced by the COVID-19 pandemic, as playing field hockey was temporarily not possible—which could have made WUP less relevant. All in all, a start with implementing WUP has been made, but there is more ground to cover. As long as WUP is a stand-alone programme, reach can probably be increased by continued use of the implementation plan, including the unused implementation channels/activities (eg, using role models). Especially social media channels seemed to work, so there might lie opportunities there (eg, working with influencers). However, it needs to be studied to what extent these channels can reach the whole target group and what the exact message should be (to stimulate adherence).
In this study, effectiveness was measured as the satisfaction with WUP, user-friendliness, and the perception of impact, since the effect of WUP on injuries was already studied.10 Our results showed that most trainers/coaches and TBMs were satisfied (overall and concerning user-friendliness) with WUP, many of them perceiving WUP as injury-preventive. Satisfaction with the delivered programme,26 perceived ease of use, and perceived usefulness can contribute to positive attitudes towards WUP and the intention to use or the actual use of WUP.27 28 Also, an implementation study regarding an effective app to prevent ankle sprains acknowledged a positive user-experience can contribute to (structural) use of an intervention,29 although it does not guarantee this. Concerning satisfaction with implementation materials, most WUP users were satisfied. Probably, thorough preparation of the implementation phase contributed to this, for example, organising implementation sessions with the target groups, drafting an implementation plan, and relying on the expertise of the KNHB in reaching the target groups.
Not everyone who registered in WUP adopted WUP and implemented it as intended. Trainers/coaches used WUP mainly inspirationally and did not use it during every training/match. Lack of adherence (the degree to which an individual chooses to pursue the suggested behavior30) was also a barrier in other injury prevention implementation studies.31 Adherence is a known challenge in implementing sports injury prevention intervention programmes, since it is a complex process in which different factors play a role.32 Concerning WUP, it can be influenced by, for instance, characteristics of the intervention itself, of the trainer/coaches or actions taken by the TBMs. In a broader context, the KNHB played a role in adherence by stimulating the target groups to use WUP through online implementation strategies at key moments during the sports season, for example, just before the start of the spring competition. However, these strategies resulted in new registrations, but affected adherence to a lesser extent. Perhaps KNHB strategies should focus more on influencing clubs and trainers/coaches’ perception towards injury risk and prevention first, possibly eventually resulting in greater programme adoption and adherence.33 When looking at how exercises were used, it turned out that instructions of the WUP exercises were not strictly followed. This is probably linked with trainers/coaches using WUP mainly for inspirational purposes. Not using an injury prevention programme as intended can reduce the programme’s effectiveness34—in literature, referred to as the ‘voltage drop’.35 36 However, adapting an injury prevention programme can also positively affect its effectiveness, as it might be better tailored to the specific user or context. Therefore, it can be argued that this is more desirable than urging users to use the injury prevention programme exactly as intended, which might cause them to stop using it completely. This is worthy of future research.
Concerning ‘maintenance’, on the individual level, most of the trainers/coaches intended to use WUP until the end of the field hockey season. However, fewer trainers intended to use WUP in every training/match. They planned to keep using it mainly inspirationally. It is unknown if trainers/coaches’ use did continue, since WUP use, for example, 6 months after the implementation period, was not studied. There are usually several challenges in long-term implementation at the setting level, such as staff turnover, slackening attention, a lack of clarity regarding goals, vision and strategy, and a lack of sense of responsibility.37 38 By embedding WUP in their Knowledge Platform and integrating WUP in education for trainers/coaches and TBMs, the KNHB partially overcomes these possible pitfalls. However, due to the non-binding character of WUP, active promotion among TBMs and trainers/coaches likely remains necessary to stimulate structural use.
Strengths and limitations
A strength of the study is the evaluation of the natural course of implementing WUP, providing insight into the real-world implementation process. Furthermore, we used the well-known RE-AIM framework to guide the evaluation.19 Although, it originally did not assess facilitators and barriers. Therefore, we complemented RE-AIM by qualitative assessments. This can further strengthen RE-AIM by providing more contextual information about the implementation process.39 Moreover, all WUP users were invited to participate in the study and share their experiences, also if they were negative. In this way, we avoided recruiting only enthusiastic participants, although still participants with an interest in the topic might be included. In addition, by conducting interviews, we were able to capture a good overview of WUP use in practice. Lastly, by combining both quantitative and qualitative data, we were able to capture the ‘story’ behind the data.
A limitation of the study could be the relatively low number of respondents. It turned out difficult to include participants in the questionnaire. One should take this into account when interpreting the results. Yet, we feel that we were able to gather as much information as possible concerning the implementation of WUP. The mixed-methods nature of the study contributed to this. Nevertheless, we only evaluated the implementation of WUP for 18 months, partly during the COVID-19 pandemic. It would be of added value to study the implementation for an additional year, since the implementation of an intervention programme takes time.40