Ekegren et al.

Injury Epidemiology 2014, 1:19

http://www.injepijournal.com/content/1/1/19

ORIGINAL CONTRIBUTION Open Access

Implementing injury surveillance systems

alongside injury prevention programs: evaluation
of an online surveillance system in a community
setting
Christina L Ekegren1*, Alex Donaldson2, Belinda J Gabbe1 and Caroline F Finch2

Abstract
Background: Previous research aimed at improving injury surveillance standards has focused mainly on issues of
data quality rather than upon the implementation of surveillance systems. There are numerous settings where
injury surveillance is not mandatory and having a better understanding of the barriers to conducting injury
surveillance would lead to improved implementation strategies. One such setting is community sport, where a lack
of available epidemiological data has impaired efforts to reduce injury. This study aimed to i) evaluate use of an
injury surveillance system following delivery of an implementation strategy; and ii) investigate factors influencing
the implementation of the system in community sports clubs.
Methods: A total of 78 clubs were targeted for implementation of an online injury surveillance system
(approximately 4000 athletes) in five community Australian football leagues concurrently enrolled in a pragmatic
trial of an injury prevention program called FootyFirst. System implementation was evaluated quantitatively, using
the RE-AIM framework, and qualitatively, via semi-structured interviews with targeted-users.
Results: Across the 78 clubs, there was 69% reach, 44% adoption, 23% implementation and 9% maintenance.
Reach and adoption were highest in those leagues receiving concurrent support for the delivery of FootyFirst.
Targeted-users identified several barriers and facilitators to implementation including personal (e.g. belief in the
importance of injury surveillance), socio-contextual (e.g. understaffing and athlete underreporting) and systems
factors (e.g. the time taken to upload injury data into the online system).
Conclusions: The injury surveillance system was implemented and maintained by a small proportion of clubs.
Outcomes were best in those leagues receiving concurrent support for the delivery of FootyFirst, suggesting that
engagement with personnel at all levels can enhance uptake of surveillance systems. Interview findings suggest
that increased uptake could also be achieved by educating club personnel on the importance of recording injuries,
developing clearer injury surveillance guidelines, increasing club staffing and better remunerating those who
conduct surveillance, as well as offering flexible surveillance systems in a range of accessible formats. By increasing
the usage of surveillance systems, data will better represent the target population and increase our understanding
of the injury problem, and how to prevent it, in specific settings.
Keywords: Injury; Surveillance; Safety; RE-AIM framework; Implementation; Qualitative; Interviews; Sport;
Australian football

* Correspondence: [email protected]
1
Department of Epidemiology and Preventive Medicine, Monash University,
Alfred Centre, 99 Commercial Rd, Melbourne, VIC 3004, Australia
Full list of author information is available at the end of the article

© 2014 Ekegren et al.; licensee Springer. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction
in any medium, provided the original work is properly credited.
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Background the challenge of encouraging club personnel to adopt

The development of successful injury prevention stra- what is essentially a voluntary task.
tegies is reliant on high-quality epidemiological data A systematic approach is required to understand and
about the incidence and severity of injuries (Holder et al. overcome the barriers to implementing surveillance sys-
2001). In order to be useful for prevention purposes, in- tems in this setting. Principles of implementation science
jury surveillance data should be reliable, valid, represen- are new to the field of injury surveillance research but
tative of the target population and recorded continually could potentially enhance these efforts. Very few studies
over time (Centers for Disease Control and Prevention have used theoretical frameworks to guide the develop-
2001). Upholding such standards is a persistent chal- ment of implementation strategies for surveillance sys-
lenge faced by those who implement and maintain injury tems (de Mheen PJ et al. 2006; Zargaran et al. 2014) and
surveillance systems. only one surveillance study has incorporated imple-
There is now a large body of research aimed at im- mentation frameworks (such as the RE-AIM framework
proving standards of practice in injury surveillance (Glasgow et al. 1999)) into its evaluation (de Mheen PJ
(Doraiswamy 1999; Ezenkwele and Holder 2001; Orchard et al. 2006). As yet, no studies have used principles of
et al. 2005; Fuller et al. 2006; McKinnon et al. 2009; Liu implementation science to systematically trial and evalu-
et al. 2009). However, much of this research has focused ate the implementation of an injury surveillance system
on issues of data quality rather than upon the implemen- in sport.
tation of injury surveillance systems (McKinnon et al. This study aimed to i) evaluate use of an online injury
2009). One of the key reasons for this is that many injury surveillance system following delivery of an implemen-
surveillance systems operate within settings where surveil- tation strategy; and ii) investigate factors influencing the
lance is mandatory, such as hospitals, where system users implementation of the system in community sports
are often obligated to conduct surveillance as part of their clubs. To address the first aim, the implementation of
role (Marson et al. 2005; Liu et al. 2009; Doraiswamy the surveillance system was evaluated using the RE-AIM
1999). Hence, there has been less need to focus on ways of framework. This framework, well-known in the field
encouraging users to adopt and maintain injury surveil- of implementation science, consists of five domains:
lance systems. reach, efficacy, adoption, implementation and mainten-
There are numerous settings where injury surveillance ance (Glasgow et al. 1999). The second aim was achieved
is not mandatory, but its implementation would greatly via a series of semi-structured interviews conducted with
enhance efforts to reduce injury (Boergerhoff et al. 1999; potential end-users of the surveillance system. These in-
Finch and Mitchell 2002; Finch 2012; Goode et al. 2014). vestigations were conducted as part of the larger NoGAPS
One such setting is community sport, where the majo- project (National Guidance for Australian Football Part-
rity of organised sports participation in Australia takes nerships and Safety), a four-year study aiming to pre-
place (Finch et al. 1999; Australian Bureau of Statistics vent injuries via an evidence-informed training program
2012). Sports participation can be associated with nu- (known as FootyFirst) in community Australian football
merous injuries and high injury-related healthcare costs clubs (Finch et al. 2011).
(Potter-Forbes and Aisbett 2003; Tovell et al. 2012), yet
through the delivery of effective injury prevention strat- Methods
egies, many sports injuries are avoidable (Gabbett 2004; Setting and background to the study
Quarrie et al. 2007; Emery et al. 2007; Steffen et al. 2008; Australian football is a popular (Standing Committee on
Gilchrist et al. 2008; Orchard and Seward 2009; Emery Sport and Recreation 2010), fast-paced contact sport
2010). To date, it has been difficult to develop effective which involves running and moving the ball by hand
injury prevention strategies and safety policies for com- (handballing) and foot (kicking) (Australian Football
munity sports settings as the majority of epidemiological League 2010). It is associated with numerous injuries
data on sports injuries have been collected on professional (Finch et al. 2013) and has the highest frequency of hos-
and elite athletes, and are not relevant to community-level pitalised injuries of any sport in Australia (Flood and
sporting populations (Finch 2012). Harrison 2006; Henley 2007). In 2011, five community
In order to obtain high-quality epidemiological data Australian football leagues (n = 78 clubs, approximately
on community sports participants, injury surveillance sys- 4000 athletes) in the state of Victoria, Australia agreed
tems are required. However, there are substantial con- to be involved in the parent project. For the purposes of
textual barriers to the implementation of such systems in this project, the five leagues were allocated to one of
community sport, including a lack of resources and a re- three study arms, each receiving a different level of sup-
liance on volunteer personnel (Donaldson et al. 2012). port for the delivery of FootyFirst (Finch et al. 2011).
Without mandating injury surveillance in community Arm 1 consisted of two regional leagues (n = 22 clubs)
sports, sports bodies and researchers are faced with in South-Western Victoria; arm 2 consisted of one large
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metropolitan league (n = 31 clubs); and arm 3 consisted to pass on an invitation to their trainer(s). Information
of two regional leagues in North-Western Victoria (n = session attendees provided their contact details to the
25 clubs). The FootyFirst program, designed to be deliv- research team to enable follow-up regarding the injury
ered by an Australian football coach, includes a combin- surveillance system. Sports trainers who did not attend
ation of dynamic stretches, strengthening exercises, and information sessions were contacted individually by
jumping/landing techniques. It is targeted at preventing phone and/or email (via their club’s coach) about partici-
ankle, knee, hamstring, groin and hip injuries in com- pating in the injury surveillance project. These recruit-
munity Australian football players (Donaldson 2014). ment procedures were repeated at the start of the 2013
To better understand the implementation context for season to capture any clubs not recruited in 2012 or
injury surveillance activities and improve the design of who had changed their sports trainers between seasons.
our implementation strategy, we asked the leagues’ Chief Monash University Human Research Ethics Committee
Executive Officers (CEOs) about the feasibility of on- granted ethics approval for all procedures.
going injury surveillance within their leagues. No league
had a mandatory injury surveillance policy in place, but Procedures
all CEOs expressed an interest in introducing one. Where The information sessions were part of a multifaceted im-
surveillance was used, club personnel (e.g. sports trainers) plementation strategy designed to maximise uptake of
used various non-standardised methods to record injuries, the system across the three study arms (described later).
mainly for their own purposes (personal communications, The strategy incorporated several core implementation
18 November, 2011). components, including training, ongoing coaching and
To further our understanding about injury surveil- consultation, and performance evaluation (Fixsen et al.
lance activities within clubs, we then conducted a 2009). The injury surveillance system implementation
pre-implementation survey of sports trainers from partici- strategy was carried out before and during the 2012 and
pating clubs within the five leagues (Ekegren et al. 2012). 2013 seasons and consisted of three main elements:
Sports trainers are non-medically trained personnel em-
ployed by sports clubs to provide first-aid and injury man- 1. Information sessions. The research team conducted
agement. In summary, 87% of the 33 respondents (32% information sessions at each league headquarters for
response rate) recorded injuries at their club on a routine sports trainers or other club personnel interested in
basis, mostly using paper-based notebooks or forms. the proposed injury surveillance system. These
Amongst respondents, attitudes towards injury surveil- sessions focused on raising awareness of the value of
lance were positive and ‘sports trainers’ were identified injury surveillance, including how to use surveillance
as those who should be primarily responsible for re- data to design and evaluate injury prevention
cording injuries at clubs. strategies. An online surveillance tool was also
demonstrated to the attendees. In two out of the
Participants and recruitment three sessions, our presentation was incorporated
When designing an implementation strategy for any ac- within a package of presentations to sports trainers
tion, the first of several core implementation components (e.g. updates on practice guidelines or instructions
to be considered is staff selection (Fixsen et al. 2009). on taping).
League CEOs and sports trainers were in agreement that 2. Personal instruction. Each information session
sports trainers were the most appropriate staff for con- attendee was contacted by phone, email or personal
ducting injury surveillance. In Australian football, sports visit and provided with further instructions about
trainers provide on-site first aid at some training sessions setting up their online surveillance account. They
and all matches, referral to external medical or allied were sent a user manual and documentation for
health experts if necessary, and ongoing injury manage- them and their coaches to sign, enrolling their club
ment (Zazryn et al. 2004; Casey et al. 2004). Sports in the project. Users were also provided with the
trainers may not have healthcare backgrounds but, in primary author’s (CLE) email address so that they
Australian football, they must all complete an endorsed could request personalised technical support as
first aid and athlete safety training course (Donaldson required. They were asked to provide a mobile
and Finch 2012). phone number and agree to receive weekly short
Before the start of the 2012 football season, league message service (SMS) reminders about recording
CEOs invited those sports trainers whose email addres- injuries throughout the season.
ses they held to attend an information session on the 3. Weekly reminders. The primary author (CLE)
proposed injury surveillance system. For many clubs, the logged onto the online system each week during the
league did not have sports trainers’ email addresses, so season to review who had recorded injuries that
instead they contacted the club’s coach and asked them week. An SMS reminder (including a request to
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inform us if there had been no new injuries) was providing free-text responses where appropriate. The in-
sent to those who had not recorded any injuries. A jury variables to be recorded in the online tool are as fol-
thank you message was sent to those who had lows (Sports Medicine Australia 2012):
recorded injuries.
1. Date of injury
Online surveillance tool and surveillance procedures 2. Type of activity at time of injury (e.g. match/training)
The Victorian branch of Sports Medicine Australia 3. Reason for presentation (e.g. new/recurrent/
(SMA), Australia’s major sports medicine advisory body, exacerbated injury)
developed Sports Injury Tracker as an online tool for re- 4. Mechanism of injury (e.g. struck by other player/etc.)
cording information about specific injury events. Users 5. Body region injured (e.g. shoulder/thigh/ etc.)
click through six pages completing a range of data fields 6. Nature of injury (e.g. abrasion/ fracture/etc.)
(Figure 1) by selecting from a list of response options or 7. Initial treatment (e.g. none/ crutches/ etc.)

Figure 1 Screenshot of the first page of six to be completed for each injury entered into the online surveillance tool.
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8. Action taken (e.g. immediate return/etc.) from 78 clubs) who attended an information session about
9. Referral (e.g. no referral/ physio/etc.) the surveillance system or had phone/email contact with a
10. Provisional severity assessment (mild/moderate/severe) research team member expressing interest in using the
11. Treating person (e.g. Medical practitioner/etc.) system. The term ‘efficacy’ is not often applied to injury
12. Return to football date surveillance systems. Instead, terms conveying the quality
of the recorded data, such as ‘validity’ or ‘completeness’
Once an injury event is recorded, a page is created are used to indicate that a surveillance system is operating
summarising the injury. Graphs and spreadsheets sum- successfully (Centers for Disease Control and Prevention
marising recorded injuries can be downloaded. A 2001). The quality of data recorded by sports trainers
paper-based version of Sports Injury Tracker system is using the online tool has been previously reported and
also available, allowing recording and transfer to the readers are referred to this publication for further details
online system at a later date [see Additional file 1]. about the ‘E’ domain of the RE-AIM framework in the
As part of their personal instructions, sports trainers context of this study (Ekegren et al. 2014. doi:10.1111/
were asked to record ‘any new football-related injury sms.12216.). ‘Adoption’ was defined as the proportion of
occurring during football training sessions or matches’ football clubs that agreed to participate and set up an
including overuse and traumatic injuries. They were online account with the intention of conducting injury
asked to do this every week, recording any new injuries surveillance. In relation to the ‘implementation’ of the sur-
occurring in the previous seven days. Before the start of veillance system, we did not consider clubs to have fully
each football season, participating sports trainers in- implemented the system if they recorded less than 10 in-
formed all athletes at their clubs about the study and juries per football season. Previous research about the fre-
gave them an opportunity to ask questions. Athletes quency of injury in community Australian football (Finch
who did not want their injury details recorded could et al. 2013) would suggest that such low injury numbers in
opt-out, but only one individual chose this option. a standard club of 50 players would be a significant under-
estimate and would indicate that surveillance had not
Evaluation been conducted with adequate diligence. Finally, ‘main-
The evaluation consisted of two parts — a quantitative tenance’ was defined as the proportion of football clubs
evaluation using the RE-AIM framework (Glasgow et al. implementing the surveillance system in 2013, after previ-
1999) and qualitative semi-structured interviews explor- ously doing so in 2012.
ing factors affecting implementation of the injury sur- The surveillance system implementation strategies
veillance system. were delivered equally across the three study arms over
both study years. However, there were differences be-
Quantitative evaluation tween the study arms in the level of support provided by
The RE-AIM framework, widely used in implementation researchers for the delivery of FootyFirst. Arm 1 received
science, consists of five domains: reach, efficacy, adop- FootyFirst with full delivery support over both years.
tion, implementation and maintenance (Glasgow et al. Arm 2 acted as the control arm in Year 1 and received
1999). As RE-AIM was originally designed to evaluate FootyFirst (with full delivery support) only in Year 2.
the public health impact of interventions (Glasgow et al. Arm 3 received FootyFirst with minimal delivery support
1999), we re-operationalised the five domains in order to over the two years (Finch et al. 2011). It was hypothe-
apply them to the implementation of an injury surveil- sised that aspects of this support, such as club en-
lance system (Table 1). For this study we defined ‘reach’ gagement, asking for clubs’ input into the project and
as the proportion of the target population (representatives assigning FootyFirst mentors to participating clubs, could

Table 1 RE-AIM domain definitions—original and re-operationalised for implementation of an injury

surveillance system
Domain Original definition (Glasgow et al. 1999) Definition as applied to an injury surveillance system
Reach Proportion of the target population that Proportion of football clubs informed about and/or trained in use of the injury
participated in the intervention surveillance system
Efficacy Success rate if implemented as in guidelines Data quality (see (Ekegren et al. 2014. doi:10.1111/sms.12216.)
Adoption Proportion of settings, practices, and plans Proportion of football clubs that agreed to participate and set up a Sports Injury
that will adopt this intervention Tracker account with the intention of conducting injury surveillance
Implementation Extent to which the intervention is The proportion of football clubs recording injuries using Sorts Injury Tracker
implemented as intended in the real world throughout season (not including clubs recording <10 injuries throughout season)
Maintenance Extent to which a program is sustained over The proportion of football clubs implementing the surveillance system in 2013 after
time doing so in 2012.
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lead to a greater compliance with all aspects of the project, Ltd, 2012) was used to assist with data analysis. Three in-
including the injury surveillance component. Therefore, terviews from each group of interviewees were randomly
RE-AIM domains were analysed separately for each selected and independently coded by the primary author
arm of the parent project. Descriptive statistics were and a research assistant to develop a common coding
used to evaluate system reach, adoption, implementa- framework consisting of fewer, higher-level themes to be
tion and maintenance. used for all subsequent coding. All interviews were then
coded by the primary author using this coding framework.
Qualitative evaluation of factors affecting implementation Six interviews were double-coded (by the primary author
of injury surveillance system and a research assistant) to enable cross-checking of data
At the end of the 2012 football season, individuals who interpretation (Barbour 2001). Where discrepancies arose,
had initially been ‘reached’ by the intervention in 2012 these were discussed and, where necessary, themes modi-
(n = 37) were contacted in random order and invited to fied further.
participate in follow-up interviews about the injury sur-
veillance system. To gauge a diverse range of opinions Results
purposive sampling was used to ensure even-capture of RE-AIM evaluation
individuals who had and had not implemented the system The results of the RE-AIM evaluation are shown in Table 3
in 2012 (Barbour 2001). The primary author conducted and Figure 2. Each of the five domains is discussed below.
and audio-recorded 30–60 minute semi-structured, face-
to-face or phone interviews using a standardised interview Reach
guide. Recruitment and interviewing continued until the Fifty four (69%) of the 78 clubs eligible across the five
primary author considered that content saturation was leagues were reached by the injury surveillance imple-
reached within both groups (Green and Thorogood 2009). mentation strategy over two years. We reached 37 clubs
The interview guide was developed based on a previous (47%) in 2012 and an additional 17 clubs (23%) in 2013.
survey carried out during the 2012 pre-season (Ekegren There were various reasons for why we did not reach
et al. 2012). It included a range of open-ended questions the remaining 24 clubs—three clubs refused to partici-
about factors influencing the implementation of the surveil- pate from the outset, the sports trainer(s) from six clubs
lance system, as well as past and current injury recording did not respond to requests for information, and we
practices and questions about the online surveillance tool. were unable to obtain the sports trainers’ details for 15
Examples of interviewer prompts are shown in Table 2. clubs. We reached the greatest proportion of clubs
Audio-recordings of the interviews were transcribed and (82%) in arm 1 and the lowest proportion in arm 3
verified by interviewees before being thematically analysed (56%). For arms 1 and 3, reach was higher in 2012 com-
using open-coding to identify key themes (Hsieh and pared to 2013 and for arm 2, reach was higher in 2013
Shannon 2005). NVivo Version 10 (QSR International Pty (Table 3).

Table 2 Examples of interviewer prompts used in semi-structured interviews

Injury surveillance practices – i.e. What do you do? Did you have a previous system in place for monitoring injuries at your club?
Please describe it.
On average, how much time do you spend each week recording injuries?
Do you intend to conduct injury surveillance next season?
Factors influencing injury surveillance practices – What were your main reasons for carrying out injury surveillance this season?
i.e. Why do you do it?
Within your football club, who should be primarily responsible for recording injuries?
Would it be helpful to be provided with more training or support on how to record injuries?
Who should provide this?
What kind of information would you like to be able to produce from your injury data?
What would you use it for?
What has been the club’s/coach’s attitude towards you carrying out injury surveillance?
Could you suggest any ways to make it easier to record injuries at your club?
Specific questions about online surveillance tool How did you first find out about Sports Injury Tracker?
What is your opinion on using an online tool to record injuries?
Have there been any difficulties accessing a computer or the internet in order to use the
online system?
Would you want to modify or adapt the system in any way?
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Table 3 Reach, adoption, implementation and maintenance (R(E)*-AIM evaluation) of online injury surveillance system
over two years
Study Arm Study year Reach Adoption Implementation Maintenance
n (%) n (%) n (%) n (%)
1 (n = 22) (Received full delivery support for FootyFirst in years 1 and 2) 1 15 (68%) 12 (55%) 7 (32%) n/a
2 11 (50%) 8 (37%) 7 (32%) 4 (18%)
Both 18 (82%) 15 (68%) 10 (46%) n/a
2 (n = 31) (Received full delivery support for FootyFirst in year 2 only) 1 10 (32%) 7 (23%) 5 (16%) n/a
2 19 (61%) 11 (36%) 2 (7%) 2 (7%)
Both 22 (71%) 15 (48%) 4 (13%) n/a
3 (n = 25) (Received minimal delivery support for FootyFirst in years 1 and 2) 1 12 (48%) 3 (12%) 3 (12%) n/a
2 6 (24%) 2 (8%) 2 (8%) 1 (4%)
Both 14 (56%) 4 (16%) 4 (16%) n/a
Total (n = 78) 1 37 (47%) 22 (28%) 15 (19%) n/a
2 36 (46%) 21 (27%) 11 (17%) 7 (9%)
Both 54 (69%) 34 (44%) 18 (23%) n/a
NB: Maintenance was always n/a for study year 1 (2012), because it was defined as the proportion of clubs that implemented the system in 2013, after already
doing so in 2012.
*NB. Readers are referred to Ekegren et al. 2014. doi: 10.1111/sms.12216 for the results of the evaluation of the ‘E’ domain of the RE-AIM framework.
Results are displayed as n clubs and percentage of total clubs per FootyFirst study arm.

Efficacy system and athlete self-report (Ekegren et al. 2014.

In our previously published study on the quality of the in- doi:10.1111/sms.12216.). Readers are referred to that study
jury surveillance data, we reported a range of data quality for full results but to summarise, we found that the profile
variables, including a) the proportion of injuries captured of injuries reported by sports trainers was consistent with
by the surveillance system compared to self-report by ath- previous studies and there was a high level of completeness
letes; b) the completeness of the data recorded in the sur- of injury records. However, we also found significant vari-
veillance system; and c) the agreement between the ability across clubs in the injury reporting rate with some
profiles of injury data recorded using the surveillance clubs greatly underreporting the frequency of injuries.

100

90

80

70
Clubs (% per arm)

60

50

40

30
Reach
20
Adoption
10
Implementation
0
Maintenance
1 (n=22)
2 (n=31)
3 (n=25)
FootyFirst Study Arm
Figure 2 Reach, adoption, implementation and maintenance of injury surveillance system over two years. Results are displayed as the
percentage of total clubs per FootyFirst study arm.
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Adoption Table 4 Demographic characteristics of interviewees who

Thirty-four (63% of the 54 clubs reached and 44% of all did/did not implement the online injury surveillance
78 clubs) clubs adopted the surveillance system as mea- system
sured by agreement to participate in the study and by Implemented Did not implement
Characteristic surveillance system surveillance system
setting up an online surveillance account. Again, we
achieved the highest level of adoption among clubs in (n) (n)
arm 1 (68%) and the lowest in arm 3 (16%). For arms 1 Role at club
and 3, adoption was higher in 2012 compared to 2013 Sports trainer 6 4
and for arm 2, adoption was higher in 2013 (Table 3). Other 0 2
Sex
Implementation
Female 2 3
Eighteen clubs (53% of the 34 clubs that adopted the
Male 4 3
surveillance system and 23% of all 78 clubs) fully imple-
mented the system by recording ten or more injuries Age group
using the online tool. A further five clubs recorded fewer 18–29 years 1 1
than ten injuries over the season and these clubs were 30–49 years 3 4
excluded from analyses. The highest level of implemen- 50 + years 2 1
tation of the surveillance system was achieved in arm 1 Time in current role
(46% of all clubs) and arm 2 demonstrated the lowest
Less than 2 years 2 1
level of implementation (13%). For arm 1, the level of
2 to 10 years 4 5
implementation was maintained from 2012 to 2013 but
for arms 2 and 3, implementation declined over the two More than 10 years 0 0
years (Table 3). Previous method of injury
recording

Maintenance Sports Injury Tracker - -

Seven clubs (47% of the 15 clubs who implemented the Other paper-based 1 3
system in 2012 and 9% of all 78 clubs) continued to im- form/notebook
plement the system in 2013. Arm 1 demonstrated the Computer spread sheet 1 1
highest level of maintenance (18% of all clubs, n = 4) and No injury recording - 2
arm 3 the lowest (4%, n = 1). The eight clubs that dis- New to club 4 -
continued using the system gave a range of reasons in- Total 6 6
cluding: the people responsible for surveillance left the
club and no one was willing to take over from them
(n = 4), technical issues with the system leading to giving
up on the system (n = 1), and reverting to a previous in-
jury recording system in a notebook because the new current role. Of the interviewees who had implemented
system was too complex for their needs (n = 1). Two the injury surveillance system, four were new to their
clubs did not give any reasons for discontinuing. role at the club and had not conducted any injury re-
cording previously (Table 4).
Qualitative evaluation
Profile of interviewees Level of implementation amongst interviewees
Twelve individuals were interviewed before content sat- Of the 12 interviewees, 6 fully implemented the online
uration was achieved. All six interviewees who had im- surveillance system. Out of the six non-implementers,
plemented the injury surveillance system and four of the five adopted the intervention (i.e. opened a Sports Injury
six who had not implemented the system were sports Tracker account) but did not record any injuries. The
trainers; the remaining interviewees were a football man- remaining non-implementer was reached by the inter-
ager and a head coach who had opted to do the injury vention (i.e. knew about the system) but did not open an
recording themselves. The interviewees had completed account, reportedly due to a lack of time. These six non-
training relevant to their roles and some also had add- implementers had either retained their previous injury
itional professional training (e.g. physiotherapy, osteop- recording methods (computer spread sheets (n = 1) and
athy, nursing, massage and emergency medical services). notebooks (n = 3)) or were not recording injuries at all
There was an even representation of males and females (n = 2). Where notebooks were used, interviewees repor-
(Table 4). Most interviewees were aged 30–49 years and ted filling these out inconsistently, with many injuries
the majority had 2–10 years of experience in their going unrecorded.
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Factors influencing surveillance system implementation culture of community Australian football (‘socio-context-
A range of factors influencing interviewees’ implemen- ual factors’); and iii) factors relating to the online sur-
tation of the surveillance system were identified. Three veillance tool itself (‘system factors’). Within these
main themes emerged from the data: i) factors that in- three main themes, key findings emerged as both facilita-
fluenced the individual responsible for conducting injury tors and barriers to implementing the injury surveillance
surveillance (‘personal factors’); ii) factors relating to so- system. These are summarised in Table 5 and discussed in
cial connections within football clubs and to the detail below.

Table 5 Factors influencing injury surveillance practices: themes and supporting quotes
Themes and key facilitators and barriers Supporting quotes
1. Personal factors
Facilitators ‘I mean, looking after upwards of sort of 70 people it’s sort of hard to keep track of a lot of the
injuries… and if that person has followed up with the advice that you’d given them or if they
Belief in the importance of injury surveillance
went and got the referral. And so, it was really to just sort of check up with people. Which is
yeah, really handy. Sort of … keeping track of everyone.’
Injury surveillance as part of sports trainer’s role ‘Oh look, I suppose I’m a little bit different to a traditional football trainer. I probably don’t meet
the mould…. And I’m just sort of hungry for those types of processes. Where I can monitor
players and I understand that you know, it does work.’
Barriers
Lack of importance placed on injury surveillance ‘I mean, we know who the people with the repeat offenders are anyway. You don’t really need a
stat saying that.’
2. Socio-contextual factors
Facilitators
Association with FootyFirst ‘So, we were trying to use them [the surveillance system and the training program]… working in
conjunction with each other so we could sort of see the benefits of the FootyFirst programme.’
Barriers
Lack of/transience of staff ‘Look, it was probably not enough. It was really all that we had. With the resources that we had
available. And staff. Sort of up until this year and last year we really haven’t had the specialists
on board … So, we’ve sort of had a limited knowledge base that we can work with.’
Underreporting of injuries ‘There’s a photo on Facebook. Soccer players pretend to be hurt, football players pretend they’re
not.’
Lack of support/leadership ‘Yeah, I think that would get more clubs involved as well. If [the league] sort of pushed it a bit
more. And even talking to the actual… the clubs over a whole. So, coaching staff and
everything. As well as the trainers. So, that everyone’s aware of it. And everyone will sort of talk
about it more.’
‘Because I mean, if you’ve got the support of the league and SMA and the club then usually
there’s no problem.’
3. System factors
Facilitators
Ease of use ‘Well, like I said I’m not the greatest on computers and I seem to… I got through it. So, I think if
I can get through it you’ve pretty much got… you’ll cover most people.’
Barriers
Time taken to upload injuries ‘It takes two seconds to write it down with a pen. It took about five minutes to enter one injury
in. … and when you have… you know, when you have ten or so injuries to record. Yeah, it took
a while.’
Technical issues ‘And then yeah, after that one time when it didn’t really work for I don’t know why it wouldn’t.
But it wasn’t really saving data at all. So, after that I did keep it in a book for probably about
four or five weeks.’
Data requirements ‘You should probably try and [cut] it down so not so many pages have to be clicked through….
Because you do have to go through a few pages. And other things that you’ve almost got to
wait for the feedback to be able to put that information in properly. You know, you’re not sure if
he’s torn that ligament.’
Adjusting to a new system ‘I’m happy to do that paperwork because generally when I do my notes, it’s during the game….
But then afterwards yeah, it’s finding that time ….I suppose that probably just didn’t work for
me because I was new at it and I hadn’t mastered the system yet.’
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1a. Personal factors facilitating injury surveillance 2b. Socio-contextual factors acting as a barrier to injury
Belief in the importance of injury surveillance surveillance
Several interviewees indicated that a belief in the im- Lack of/transience of staff
portance of injury surveillance was a strong motivator For most non-implementers, a lack of staff was cited as
for them to engage in the practice. Interviewees gave a a key barrier to conducting injury surveillance. Several
range of reasons for the importance of injury surveil- clubs only had two sports trainers on staff and they
lance, including: i) to act as a memory aid; ii) to facilitate struggled to keep up with the usual demands of their
communication between club personnel (e.g. within the role without engaging in extra duties. One interviewee
first aid/medical team or between trainers and coaches); felt that an absence of ‘specialist’ staff at their club (e.g.
iii) for legal reasons (e.g. advice given to athletes follow- physiotherapists) precluded them from recording injur-
ing injury); and iv) to try to determine injury causation ies and implied that sports trainers were not suitable for
and develop injury prevention strategies. Where clubs the task.
had implemented the injury surveillance system, it was Before the start of the following football season, 4 of
maintained only through the diligence of the individual the 12 interviewees resigned from their roles at the
responsible. It was apparent that those interviewees who clubs. Two doubted whether anyone else would continue
had implemented the system had a personal interest in recording injuries in their absence. This transience of
the process and were intrinsically motivated to continue. staff may be due to the working conditions of sports
trainers, with several interviewees commenting that be-
ing a sports trainer was almost like being a volunteer, i.e.
Injury surveillance part of sports trainer’s role not highly paid, and done for the experience or love of
Interviewees who had implemented the surveillance sys- the sport.
tem generally felt responsible for injury surveillance at
their club. They acknowledged that recording injuries Underreporting of injuries
took extra time and was beyond their normal duties yet The majority of interviewees raised the issue of athlete
they did not consider this unreasonable, with one inter- underreporting of injuries as a barrier to injury surveil-
viewee stating ‘two to four hours a week for me would lance. Some reported that athletes did not want to reveal
be nothing’. their injuries in case this resulted in them missing a
match. This desire to play when injured was compounded
1b. Personal factors acting as a barrier to injury by the attitudes of some coaches who also encouraged
surveillance athletes to play when injured. It was also reported that
Lack of importance placed on injury surveillance athletes often ignored their injuries, refusing to seek help
Two interviewees who did not record injuries considered from trainers or other health professionals and continuing
the formal process of injury surveillance to be unimport- to play. The reasons for this include athletes being unable
ant because they believed they could remember all of or unwilling to pay for treatment by external health pro-
their athletes’ injuries without writing them down. One fessionals, or athletes not considering themselves injured.
also felt that club-based record keeping was unnecessary,
as injuries were recorded by the treating physiotherapist Lack of support/leadership
external to the club. Another interviewee suggested that While many coaches had initially encouraged trainers to
clubs within their league did not want to conduct sur- use the injury surveillance system, most interviewees
veillance because such practices would be seen as ‘taking reported that coaches and club administrators were not
it all a bit too seriously’. interested in the specific injury surveillance outcomes.
Even when interviewees had analysed injury data to cre-
ate end-of-season summary reports, they did it for per-
2a. Socio-contextual factors facilitating injury surveillance sonal interest rather than for anyone else at the club.
Association with FootyFirst For the most part, sports trainers felt that coaches were
In most cases, the interviewee was initially told about interested in ascertaining who could play each week, not
and encouraged to use the injury surveillance system by using the data for injury prevention purposes.
their club’s coach or president (who had heard about the Regardless of whether they had implemented the sur-
system from the research team). Coaches who decided veillance system or not, interviewees felt that more sup-
to be involved with the FootyFirst program also encour- port from their coach, club, and league would have helped
aged their trainers to sign up to use the surveillance sys- to facilitate ongoing injury surveillance. When asked whe-
tem. Five of the six implementers, but only two of the ther, at the conclusion of the project, there should be a
six non-implementers interviewed were from clubs that body responsible for carrying on the administration and
had agreed to be involved with FootyFirst. support for the online system and if so, who this should
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be, many interviewees felt that the peak sports medicine issues raised concerning the reporting functions and the
authority, SMA, should fulfil this role. ability to filter injuries based on teams.

3a. System factors facilitating injury surveillance Data fields

Ease of use Some interviewees felt that too much detail was required
Several interviewees commented that, although they had for each injury and that certain information, such as the
limited computer skills, they were able to use the system. injury diagnosis, was often unavailable at the time of in-
When asked whether the training they received was ad- jury. Others were not satisfied with the response options
equate or if they would have found the system easier for certain data fields. In particular, three interviewees
to use with more thorough training, most interviewees mentioned that the options for the mechanism of injury
(including those who did not implement the system) could be more detailed. One interviewee also commented
thought the system was self-explanatory and no more that the paper-based form differed to the online version
training was necessary. However, it was universally ac- which added to the challenge of transferring data at a
knowledged that individuals who were completely un- later date.
familiar with computers would probably struggle to use
the online system. Adjusting to a new system
Four of the six non-implementers continued using their
pre-existing injury recording system rather than chan-
3b. System factors acting as a barrier to injury ging to the new online system. Most of these individuals
surveillance recorded injuries in notebooks, preferring the immediacy
Time taken to upload injuries and simplicity of this format compared to the online sys-
Most interviewees acknowledged that entering infor- tem. Conversely, four of the six implementers were new
mation into the system increased the time and the effort to their role at the club and therefore, were happy to try
required to record injuries. This was the major barrier the new system in the absence of a pre-existing alternative.
cited by non-implementers. Several interviewees recor-
ded injuries on the paper-based version of the form or Discussion
in a notebook during training and matches, and then We aimed to evaluate the use of an injury surveillance
uploaded the data onto the system later. The time spent system in a community sports setting and describe rele-
doing this ranged from 15 minutes to 2 hours per week. vant barriers and facilitators. For injury surveillance data
To streamline the process, some interviewees tried re- to be useful for injury prevention purposes it must be
cording injuries using their smart phones as soon as they both high-quality and representative of a large proportion
occurred. However, there was no mobile version or mobile of the target population (Centers for Disease Control and
application (‘app’) for the online tool and it was difficult to Prevention 2001). This study was unique in that most pre-
use the system on such devices. Several interviewees sug- vious research on injury surveillance systems has focused
gested that an app should be developed. on factors influencing data quality rather than on factors
How interviewees interpreted the definition of a re- influencing the implementation of the system (McKinnon
cordable injury also influenced the amount of time spent et al. 2009). In sport, there have been no studies that have
recording injuries. Some interviewees recorded all injur- used principles of implementation science to systematic-
ies including lacerations and bruises while others only ally trial and evaluate the implementation of an injury sur-
recorded more serious injuries leading to an athlete miss- veillance system.
ing a match. Many interviewees agreed that a narrower in- We evaluated the reach, adoption, implementation and
jury definition would reduce the amount of time they maintenance of the injury surveillance system over two
spent recording injuries. consecutive football seasons. In a previous study, we also
evaluated system efficacy over a single season (Ekegren
Technical issues et al. 2014. doi:10.1111/sms.12216.). In relation to the
Three interviewees commented on technological issues four RE-AIM domains measured in the present study,
they had experienced with the system including the length the proportions of clubs achieving reach (69%) and
of time it took to load, leading to it taking too long to re- adoption (44%) were a reasonable representation of the
cord each injury. Also, sometimes injury details did not 78 clubs targeted. However, the proportions of clubs
save properly and had to be re-entered. One user also implementing (23%) and maintaining the system (9%)
tried to link several colleagues within their club so that were low. Consistent with key implementation-science
they could all log in and view the system. However, the concepts, the implementation strategy was developed
process was quite complicated and there were no instruc- following consultation with multiple tiers of influence,
tions in the user manual to guide this. There were other including league administrators and system-users, and
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was based on several core implementation components voluntary reporting systems, offering financial or add-
(Finch and Donaldson 2010; Fixsen et al. 2009). How- itional human resource incentives can increase engage-
ever, the poor outcomes achieved in the implementation ment or else the system is reliant solely on the motivation
and maintenance of the injury surveillance system sug- of individuals keen to improve the quality of practice (de
gests that our implementation strategy was inadequate Mheen PJ et al. 2006).
or inappropriate for this setting. Our study identified important socio-contextual factors
Although the implementation strategy for the surveil- influencing the implementation of the injury surveillance
lance system was the same for all study arms, there were system. The most commonly reported contextual barrier
marked differences in the RE-AIM outcomes between was the underreporting of injuries by football players
the arms (Table 3). These differences appear to relate to to avoid missing matches. An attitude of invincibility
the level of support provided for the delivery of Footy- amongst players was also reported, such that injuries were
First (Finch et al. 2011). Within leagues receiving full de- possibly seen as a sign of weakness. Injury underreporting
livery support for FootyFirst (study arm 1 (in 2012 and has been recognised in other contexts where physical
2013) and study arm 2 (in 2013)), there was a high pro- toughness is valued (e.g. in the defence forces) (McKinnon
file launch for the project and extensive personal contact et al. 2009). Other important barriers included inadequate
between the research team and club personnel, including staffing levels and a lack of support for ongoing surveil-
coaches, presidents and sports trainers. There was also lance from leaders and administrators. The influence of
encouragement from the league to participate in Footy- peer leadership and social support has been well docu-
First and information provided to clubs about it. These mented in relation to the use of surveillance systems
actions may have helped to endorse the research team (de Mheen PJ et al. 2006; Ezenkwele and Holder 2001;
and the entire project, including the surveillance system. Gambel et al. 1999; Spaite et al. 1990; Boergerhoff et al.
Results from the qualitative evaluation supported this, 1999; Finch and Mitchell 2002).
with interviewees perceiving a close link between the in- These findings of the importance of socio-contextual
jury surveillance system and the injury prevention pro- factors are accordant with Fixsen et al’s core implementa-
gram. Also, coaches who had decided to implement tion components (Fixsen et al. 2005), i.e. ‘the most essen-
FootyFirst often encouraged their sports trainers to tial and indispensable components of an implementation
engage with the project, which would have influenced practice or program’ (Fixsen et al. 2005). The core com-
the reach and adoption of the system. In 2013, when ponents can be categorised as those addressing the
full support for FootyFirst was provided to study arm competency of the individual, organisational factors
2, reach and adoption increased. However, the level and leadership issues (Donaldson and Finch 2013). The
of implementation decreased. Therefore, it is likely implication is that it is insufficient to provide training and
that the support for the delivery of FootyFirst influ- coaching to individual practitioners without also targeting
enced the reach and adoption of the surveillance system, those in leadership roles and addressing organisational
but not its implementation. Other potential influences on and cultural barriers. The findings of this study suggest
implementation were explored further via the qualitative that our implementation strategies focused too heavily on
evaluation. the competency of those charged with implementing the
Because injury surveillance is optional in community surveillance system (e.g. staff selection, training, coaching
sport, personal factors impacting on implementation of and evaluation) without adequately addressing organisa-
the surveillance system were common. For example, a tional issues (e.g. system interventions and administration)
belief in the importance of surveillance was a key theme. or leadership drivers (e.g. role of senior coach and other
Recognising injury surveillance as part of the sports club leaders) (Fixsen et al. 2005; Donaldson and Finch
trainer’s role influenced implementation and the amount 2013). Uptake was highest in the FootyFirst study arms re-
of time interviewees were willing to spend recording injur- ceiving maximum program delivery support across mul-
ies. It was evident that a passion for the job motivated sev- tiple tiers of influence, including league administrators,
eral interviewees to engage in these extra duties outside of coaches and club presidents, highlighting the import-
normal working hours. Other studies evaluating user ex- ance of organisational and leadership drivers (Finch and
periences of injury surveillance systems have reported that Donaldson 2010).
outcomes are enhanced when users have accountability Interviewees’ perceptions of the online surveillance tool
for recording injury data (Ezenkwele and Holder 2001; indicated that some were frustrated by the extra step in-
Porcheret et al. 2004; Doraiswamy 1999; de Mheen PJ volved in uploading paper records (filled out at the time of
et al. 2006). For example, a Dutch hospital-based study injury) to the online tool at a later time. As suggested by
highlighted a lack of accountability as a key barrier to the previous studies (Goode et al. 2014), a smartphone or
implementation of an adverse-outcome reporting system tablet ‘app’ would help address these concerns. Fixing the
(de Mheen PJ et al. 2006). They suggested that, with technical glitches with the system experienced by some
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interviewees would also encourage more users to perse- of injury surveillance within community sport heightens
vere with the system. These two barriers are supported by the influence of an intrinsic belief in the importance of the
the Diffusion of Innovations construct of ‘complexity’ practice. To increase understanding of the importance of
which suggests ‘the complexity of an innovation, as per- injury surveillance, all club personnel should be educated
ceived by members of a social system, is negatively related on the importance of recording injuries for legal, commu-
to its rate of adoption’ (Rogers 2003). In other words, the nication and injury prevention (and consequently athlete
more difficult an injury surveillance system is perceived or and team performance) purposes. To avoid injury under-
experienced to be, the fewer the number of people who reporting, athletes and coaches should be educated on the
will be prepared to adopt and implement it. The need for importance of reporting injuries and on taking the ne-
simplicity and utility is well supported by previous litera- cessary steps to ensure injuries are rehabilitated prop-
ture on surveillance systems (Goode et al. 2014; Finch erly before returning to play. Underreporting may also
et al. 1999; McKinnon et al. 2009; Zargaran et al. 2014). be reduced by providing athletes and coaches with a
Another commonly reported barrier was the difficulty standardised definition of a reportable injury. Based on
changing to a new system when there was a pre-existing our finding of greater implementation of the injury sur-
system in place. This barrier has been reported previ- veillance system among clubs receiving full support for
ously in surveillance research (de Mheen PJ et al. 2006; the delivery of FootyFirst, it would appear that there is
Finch et al. 1999) and is also consistent with the Diffu- great benefit in engaging with coaches, club presidents
sion of Innovations construct of ‘compatibility’ which is and league officials about injury surveillance. Therefore,
‘the degree to which an innovation is perceived as con- sporting leagues should support injury surveillance prac-
sistent with existing values, past experiences and needs tices and create clear guidelines as to their expectations.
of potential adopters’ (Rogers 2003). Hence, there may Clubs, leagues and governing bodies should also appreci-
be a need for a more flexible approach to surveillance in ate the workload of sports trainers and seek to increase
community sport such as continuing to provide standar- staffing levels and remuneration for these individuals. Fi-
dised paper-based reporting forms rather than expecting nally, online tools can be made more accessible by devel-
all clubs to implement computerised online systems. This oping smartphone and tablet applications and by reducing
preference for dual reporting methods has been raised technical issues. Additionally, acknowledging that not all
previously in other settings (Goode et al. 2014; McKinnon users will easily adapt to new technology, there is a need
et al. 2009). Our results also suggest that new staff mem- to be flexible in offering different modes of surveillance,
bers may be less resistant to using a new surveillance sys- including paper-based forms.
tem and therefore, their arrival at a club may present an
opportunity for a change in injury surveillance practices. Conclusions
This is consistent with literature on habit theory which This research offers important insights into the factors
highlights the enabling effect of new contexts on new be- affecting the implementation of injury surveillance sys-
haviours (Nilsen et al. 2008). tems in community sports settings. We achieved a re-
There may be study limitations which diminish the ex- latively low level of implementation and maintenance
ternal validity of our findings. Although we purposively following delivery of our implementation strategy. How-
sampled to achieve a balance of views by recruiting par- ever, results were best in those leagues that were receiv-
ticipants who consistently used the online surveillance ing concurrent delivery support for an injury prevention
system and those who did not, all interviewees had prior program, suggesting that greater levels of engagement
knowledge of, and possibly an interest in injury surveil- with staff at all levels and with relevant organisations
lance and their views may not be representative of the can enhance uptake. Personal factors, such as a belief in
broader population of sports trainers. Also, our sample the importance of injury surveillance were influential, as
size was relatively small (n = 12) although, despite this, were socio-contextual factors, such as athlete under-
we did achieve saturation of content amongst our inter- reporting and understaffing. Finally, to increase reach,
viewees. Finally, we conducted this study within a sport adoption, implementation and maintenance, surveillance
that is relatively well-organised, in terms of sports trai- systems should be user-friendly and delivered in a range
ner staffing. In other sports, contextual barriers, such as of accessible formats. The findings of this research should
a lack of resources and staff, could be more significant be considered when attempting to improve the uptake of
than they were within Australian football, making some injury surveillance systems in sports and other settings
of the recommendations harder to implement and the where surveillance is optional. By increasing uptake of sur-
findings less generalisable. veillance systems, surveillance data will represent a greater
Based on our findings, there are a number of practical proportion of the target population and increase our un-
suggestions to improve the implementation of injury sur- derstanding of the extent of the injury problem in specific
veillance systems in similar settings. The voluntary nature settings.
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Abbreviations Centers for Disease Control and Prevention. Updated guidelines for evaluating
SMA: Sports medicine Australia; NoGAPS: National guidance for Australian public health surveillance systems: recommendations from the guidelines
football partnerships and safety; CEO: Chief executive officer; AFL: Australian working group. MMWR Morb Mortal Wkly Rep. 2001; 50(RR-13):1–36.
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Competing interests 46(10):759–65.
The authors declare that they have no competing interests. Donaldson A, Finch CF. Applying implementation science to sports injury
prevention. Br J Sports Med. 2013; 47(8):473–75.
Authors’ contributions Donaldson A, Leggett S, Finch CF. Sports policy development and
CLE conceived the study, collected data, analysed data and had major implementation in context: researching and understanding the
responsibility for the paper writing. AD, BJG and CFF contributed to the perceptions of community end-users. Int Rev Sociol Sport. 2012;
design of the study and the writing of the paper. BJG and CFF are chief 47(6):745–60.
investigators of the larger NoGAPS project that this study is nested within. Doraiswamy NV. Injury surveillance in a children's hospital–overcoming
All authors read and approved the final manuscript. obstacles to data collection. J Accid Emerg Med. 1999; 16(3):189–93.
Ekegren C, Donaldson A, Gabbe B, Sheehan L, Finch C. Sports trainers’ attitudes
Acknowledgments towards injury surveillance in community Australian Football. J Sci Med
The authors are grateful to all of the athletes, sports trainers, club personnel Sport. 2012; 15(Supplement 1):S129–30.
and league CEOs who participated in this study. We thank Alyse Lennox Ekegren CL, Gabbe BJ, Finch CF. Injury surveillance in community sport: Can
(Department of Epidemiology and Preventive Medicine, Monash University) we obtain valid data from sports trainers? Scand J Med Sci Sports. 2014;
for her assistance with qualitative analysis and James Tantau and Tim doi:10.1111/sms.12216.
Lathlean for their assistance with recruitment. Thank you also to Professor Jill Emery CA. The effectiveness of a neuromuscular prevention strategy to
Cook (Department of Physiotherapy, School of Primary Health Care, Monash reduce injuries in youth soccer: a cluster-randomised controlled trial.
University) and Professor David Lloyd (Centre for Musculoskeletal Research, Br J Sports Med. 2010; 44(8):555–62.
Griffith Health Institute, Griffith University) for their contributions as co-chief Emery CA, Rose MS, McAllister JR, Meeuwisse WH. A prevention strategy to
investigators of the NoGAPS research project. reduce the incidence of injury in high school basketball: a cluster
randomized controlled trial. Clin J Sport Med. 2007; 17(1):17–24.
Funding Ezenkwele UA, Holder Y. Applicability of CDC guidelines toward the
Christina Ekegren is supported by a National Health and Medical Research development of an injury surveillance system in the Caribbean. Inj Prev.
Council (NHMRC) Public Health postgraduate scholarship (ID: 1055445) and, 2001; 7(3):245–48.
prior to 2013, was supported by a departmental scholarship funded through Finch C, Donaldson A. A sports setting matrix for understanding the
an NHMRC Partnership Project Grant (ID: 565907). Belinda Gabbe is implementation context for community sport. Br J Sports Med. 2010; 44:973–78.
supported by an NHMRC Career Development Fellowship (ID: 1048731). Finch CF, Gabbe BJ, Lloyd D, Cook J, Young W, Nicholson M, Seward H,
Caroline Finch was supported through NHMRC Principal Research Donaldson A, Doyle T. Towards a national sports safety strategy –
Fellowships (ID: 565900 and ID: 1058737). This research was conducted as addressing facilitators and barriers towards safety guideline uptake
part of the NoGAPS study, funded by an NHMRC Partnership Project Grant (the NoGAPS project). Inj Prev. 2011; 17(3):1–10.
(ID: 565907) with additional support (both cash and in-kind) from the project Finch C, Ozanne SJ, Valuri G. Injury surveillance during medical coverage of
partner agencies: the Australian Football League (AFL); Victorian Health sporting events - development and testing of a standardised data
Promotion Foundation (VicHealth); NSW Sporting Injuries Committee collection form. J Sci Med Sport. 1999; 2:42–56.
(NSWSIC); JLT Sport, a division of Jardine Lloyd Thompson Australia Pty Finch CF. Getting sports injury prevention on to public health agendas -
Ltd (JLT Sport); Department of Planning and Community Development, addressing the shortfalls in current information sources. Br J Sports Med.
Sport and Recreation Victoria Division (SRV); and Sports Medicine Australia, 2012; 46(1):70–4.
National and Victorian Branches (SMA). The Australian Centre for Research into Finch CF, Gabbe BJ, White P, Lloyd D, Twomey D, Donaldson A, Elliott B, Cook J.
Injury in Sport and its Prevention (ACRISP) is one of the International Research Priorities for investment in injury prevention in community Australian
Centres for Prevention of Injury and Protection of Athlete Health supported by football. Clin J Sport Med. 2013; 23(6):430–38.
the International Olympic Committee (IOC). Finch CF, Mitchell DJ. A comparison of two injury surveillance systems within
sports medicine clinics. J Sci Med Sport. 2002; 5:321–35.
Author details Fixsen DL, Blase KA, Naoom SF, Wallace F. Core implementation components.
1
Department of Epidemiology and Preventive Medicine, Monash University, Res Soc Work Pract. 2009; 19(5):531–40.
Alfred Centre, 99 Commercial Rd, Melbourne, VIC 3004, Australia. 2Australian Fixsen DL, Naoom SF, Blase KA, Friedman RM, Wallace F. Implementation research:
Centre for Research into Injury in Sport and its Prevention, Federation a synthesis of the Literature, FMHI Publication #231. Tampa, FL: University of
University Australia, Ballarat, VIC 3353, Australia. South Florida, Louis de la Parte Florida Mental Health Institute, The National
Implementation Research Network; 2005.
Received: 22 May 2014 Accepted: 28 June 2014 Flood L, Harrison JE. Hospitalised sports injury, Australia 2002–03, Injury Research
and Statistics, Volume 27. Adelaide (SA): Australian Institute of Health and
Welfare; 2006. AIHW cat no. INJCAT 79.
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