Supported implementation enhances injury prevention programme (Prep-to-Play) use in women and girls playing Australian Football: a pragmatic type III hybrid implementation-effectiveness stepped wedge cluster randomised trial

Objectives Evaluate the effect of supported implementation on a co-created injury prevention programme (Prep-to-Play) use and injury incidence and evaluate the dose response relationship between adherence and injury incidence. Methods In this hybrid implementation-effectiveness stepped wedge cluster randomised trial, 165 women’s/girls’ Australian Football teams (2481 players) were randomly allocated to transition from unsupported to supported implementation at one of five time points during 2021/2022. Supported implementation included in-person workshops and support visits for coaches/team leaders. Unsupported implementation was access to online resources. Prep-to-Play includes warm-up, contact and strength activities. Primary (Prep-to-Play use) and secondary (concussion, anterior cruciate ligament (ACL)) outcomes were reported weekly. Weekly Prep-to-Play use (yes/no) was defined as using ≥75% of programme elements, ≥two-thirds of sessions each week. Analyses compared outcomes between supported and unsupported phases, adjusted for clustering, period, age group, competition level and region. Results Average weekly Prep-to-Play use by teams was 13.1% (95% CI 11.5% to 14.9%) in the unsupported and 29.7% (95% CI 27.6% to 31.9%) in supported phase (OR 3.7 95% CI 2.4 to 5.7). The concussion and ACL injury incidence (per 1000 game hours) was 6.80 (95% CI 5.75 to 8.05) and 1.36 (95% CI 0.98 to 1.89) in unsupported, and 3.50 (95% CI 2.72 to 4.52) and 0.69 (95% CI 0.44 to 1.15) in supported, respectively, but the effect of supported implementation on injury incidence was unclear (concussion: incidence rate ratios (IRR) 1.36; 95% CI 0.74 to 2.49; ACL: IRR 2.27 (0.56 to 9.12). Higher Prep-to-Play adherence was associated with fewer total injuries (IRR: 0.95 95% CI 0.92 to 0.99). Conclusions Supported implementation via in-person workshops and support visits was associated with greater Prep-to-Play use compared with unsupported implementation, and greater adherence was associated with fewer injuries. Trial registration number NCT04856241 .