The Intervention Mapping (IM) protocol (Bartholomew et al., 2016)
Intervention Mapping is a planning approach that is based on using theory and evidence to assessing and intervening in health problems and community participation.
- Conduct a needs assessment or problem analysis, identifying what, if anything, needs to be changed and for whom;
In Step 1, before beginning to actually plan an intervention, the planner assesses the health problem, its related behavior and environmental conditions, and their associated determinants for the at-risk populations. This assessment encompasses two components: a scientific, epidemiologic, behavioral, and social perspective of an at-risk group or community and its problems; and an effort to “get to know,” or begin to understand, the character of the community, its members, and its strengths. The product of this first step is a description of a health problem, its impact on quality of life, behavioral and environmental causes and determinants of behavior and environmental causes.
In Step 1, the planner completes the following tasks:
- Establish and work with a planning group
- Conduct a needs assessment to create a logic model of the problem
- Describe the context for the intervention, including the population, setting, and community
- State program goals
2. Create matrices of change objectives by combining (sub-)behaviors (performance objectives) with behavioral determinants, identifying which beliefs should be targeted by the intervention
Step 2 provides the foundation for the intervention by specifying who and what will change as a result of the intervention. In order to develop performance objectives beyond the individual, roles are identified at each selected ecological level. Statements of what must be changed at each ecological level and who must make the change, are more specific intervention foci than are traditional program goals and objectives.
In Step 2 the planner completes the following tasks:
- State expected outcomes for behavior and environment
- Specify performance objectives for behavioral and environmental outcomes
- Select determinants for behavioral and environmental outcomes
- Construct matrices of change objectives
- Create a logic model of change
3. Select theory-based intervention methods that match the determinants into which the identified beliefs aggregate, and translate these into practical applications that satisfy the parameters for effectiveness of the selected methods;
In Step 3, the planner seeks theory-informed methods and practical strategies to effect changes in the health behavior of individuals and related small groups and to change organizational and societal factors to affect the environment. An intervention method is a defined process by which theory postulates and empirical research provides evidence for how change may occur in the behavior of individuals, groups, or social structures. Whereas a method is a theory-based technique to influence behavior or environmental conditions, a strategy is a way of organizing and operationalizing the intervention methods.
In Step 3, the planner completes the tasks of:
- Generate program themes, components, scope, and sequence
- Choose theory- and evidence-based change methods
- Select or design practical applications to deliver change methods
4. Integrate methods and the practical applications into an organized program;
The products in Step 4 include a description of the scope and sequence of the components of the intervention, completed program materials, and program protocols. This step demands the careful reconsideration of the intended program participants and the program context. It also requires pilot testing of program strategies and materials with intended implementers and recipients. This step gives specific guidance for communicating program intent to producers (e.g., graphic designers, videographers, and writers).
In Step 4, the planner completes the following tasks:
- Refine program structure and organization
- Prepare plans for program materials
- Draft messages, materials, and protocols
- Pretest, refine, and produce materials
5. Plan for adoption, implementation and sustainability of the program in real-life contexts;
The focus of Step 5 is program adoption and implementation (including consideration of program sustainability). Of course, considerations for program implementation actually begin as early as the needs assessment and are revisited in this step. The step requires the process of matrix development exactly like that in Step 2 except that these matrices are developed with adoption and implementation performance objectives juxtaposed to personal and external determinants. The linking of each performance objective with a determinant produces a change objective to promote program adoption and use. These objectives are then operationalized using methods and strategies to form theory-informed plans for adoption and implementation. The product for Step 5 is a detailed plan for accomplishing program adoption and implementation by influencing behavior of individuals or groups who will make decisions about adopting and using the program.
In Step 5, the planner completes the following tasks:
- Identify potential program users (adopters, implementers, and maintainers)
- State outcomes and performance objectives for program use
- Construct matrices of change objectives for program use
- Design implementation interventions
6. Generate an evaluation plan to conduct effect and process evaluations.
In Step 6, the planner finalizes an evaluation plan that is actually begun in the needs assessment and is developed along with the intervention map. In the process of Intervention Mapping, planners make decisions about change objectives, methods, strategies, and implementation. The decisions, although informed by theory and evidence from research, still may not be optimal or may even be completely wrong. Through effect and process evaluation, planners can determine whether decisions were correct at each mapping step. To evaluate the effect of an intervention, researchers analyze the change in health and quality of life problems, behavior and environment, and determinants of performance objectives. All these variables have been defined in a measurable way during the preceding steps. The product of Step 6 is a plan for answering these questions.
In Step 6, the planner completes the following tasks:
- Write effect and process evaluation questions
- Develop indicators and measures for assessment
- Specify the evaluation design
- Complete the evaluation plan
Step 1: Use the research evidence and clinical experience
This initial step is necessary to maximize the likelihood that the developed intervention will “work” by ensuring firm grounding in the available epidemiologic and etiological evidence.
Step 2: Consult the experts
This step ensures that the developed intervention is specific to the sport and injury mechanisms of interest. Experts working in clubs and other environments were invited to participate in an consensus-generating approach to critically assess the content.
Step 3: Engage end users
Development of any intervention requires that the proposed strategies and program components are relevant and acceptable to potential program deliverers (e.g., strength and conditioning staff, coaches, etc.) and participants (e.g., athletes, players, etc.).
Step 4: Test the feasibility and acceptability of the intervention
Before assessing intervention efficacy, the feasibility and acceptability of an intervention should be tested to be confident that it can be delivered as intended and that participants can successfully complete all required tasks.The postexpert consultation version of the program was tested on physiotherapy students, who were all community-level athletes, were videotaped and photographed performing the exercises correctly and incorrectly (August 2011). A coach was given the revised
Step 5: Evaluate against theory
When developing an intervention, 1-way to enhance the likelihood of its adoption, implementation, and maintenance by the target audience in the real-world setting is to evaluate it against a relevant theory.
Step 6: Obtain feedback from early implementers
Despite all the effort invested in steps 1-5, it is not guaranteed that the process will develop a perfect intervention, especially at the first attempt. Therefore, it is useful to ask end users to use the intervention in their settings and obtain feedback from them about the content and presentation before the intervention is formally evaluated.
Injury prevention programmes have little population health impact if they are not evidence-based and used widely.1 Programme effects have been shown to be up to three times higher when programmes are well implemented.2 Without a systematic and evidence-informed approach to programme implementation, conclusions of limited effectiveness will be made based on poor implementation.3 Structured implementation planning frameworks can help to reduce the research-to-practice gap and maximise programme impact by increasing the use of evidenced-based programmes in communities.
METHODS Intervention Mapping (IM) facilitates effective health promotion programme planning, implementation and evaluation.24 IM Step 5, which can be used independently of other IM steps, focuses on planning programme adoption, implementation and maintenance.24 It comprises seven tasks that are operationalised through six core processes.
Seven Steps for Developing and Implementing a Preventive Training Program Lessons Learned from JUMP-ACL and Beyond
BackgroundSports participation can be associated with numerous injuries and high injury-related healthcare costs (Potter-Forbes and Aisbett 2003; Tovell et al. 2012), yet through the delivery of effective injury prevention strategies, many sports injuries are avoidable (Gabbett 2004; Quarrie et al. 2007; Emery et al. 2007; Steffen et al. 2008; Gilchrist et al. 2008; Orchard and Seward 2009; Emery 2010). To date, it has been difficult to develop effective injury prevention strategies and safety policies for community sports settings as the majority of epidemiological data on sports injuries have been collected on professional and elite athletes, and are not relevant to community-level sporting populations (Finch 2012).
In order to obtain high-quality epidemiological data on community sports participants, injury surveillance systems are required. However, there are substantial contextual barriers to the implementation of such systems in community sport, including a lack of resources and a reliance on volunteer personnel (Donaldson et al. 2012).
Without mandating injury surveillance in community sports, sports bodies and researchers are faced with the challenge of encouraging club personnel to adopt what is essentially a voluntary task.
only one surveillance study has incorporated implementation frameworks (such as the RE-AIM framework (Glasgow et al. 1999)) into its evaluation (de Mheen PJ et al. 2006). As yet, no studies have used principles of implementation science to systematically trial and evaluate the implementation of an injury surveillance system in sport.
To address the first aim, the implementation of the surveillance system was evaluated using the RE-AIM framework. This framework, well-known in the field of implementation science, consists of five domains: reach, efficacy, adoption, implementation and maintenance (Glasgow et al. 1999)
The injury surveillance system implementation strategy was carried out
- Information sessions. The research team conducted information sessions at each league headquarters for sports trainers or other club personnel interested in the proposed injury surveillance system. These sessions focused on raising awareness of the value of injury surveillance, including how to use surveillance data to design and evaluate injury prevention strategies. An online surveillance tool was also demonstrated to the attendees. In two out of the three sessions, our presentation was incorporated within a package of presentations to sports trainers (e.g. updates on practice guidelines or instructions on taping).
- Personal instruction. Each information session attendee was contacted by phone, email or personal visit and provided with further instructions about setting up their online surveillance account. They were sent a user manual and documentation for them and their coaches to sign, enrolling their club in the project. Users were also provided with the primary author’s (CLE) email address so that they could request personalised technical support as required. They were asked to provide a mobile phone number and agree to receive weekly short message service (SMS) reminders about recording injuries throughout the season
- Weekly reminders. The primary author (CLE) logged onto the online system each week during the season to review who had recorded injuries that week. An SMS reminder (including a request to inform us if there had been no new injuries) was sent to those who had not recorded any injuries. A thank you message was sent to those who had recorded injuries.
Online surveillance tool and surveillance procedures The Victorian branch of Sports Medicine Australia (SMA), Australia’s major sports medicine advisory body, developed Sports Injury Tracker as an online tool for recording information about specific injury events. Users click through six pages completing a range of data fields (Figure 1) by selecting from a list of response options or providing free-text responses where appropriate. The injury variables to be recorded in the online tool are as follows (Sports Medicine Australia 2012): 1. Date of injury 2. Type of activity at time of injury (e.g. match/training) 3. Reason for presentation (e.g. new/recurrent/ exacerbated injury) 4. Mechanism of injury (e.g. struck by other player/etc.) 5. Body region injured (e.g. shoulder/thigh/ etc.) 6. Nature of injury (e.g. abrasion/ fracture/etc.) 7. Initial treatment (e.g. none/ crutches/ etc.) 8. Action taken (e.g. immediate return/etc.) 9. Referral (e.g. no referral/ physio/etc.) 10. Provisional severity assessment (mild/moderate/severe) 11. Treating person (e.g. Medical practitioner/etc.) 12. Return to football date
Conceptual models and frameworks from the broader field of health promotion can potentially facilitate the translation of efficacious interventions into practice, and examples of applying implementation science to sports injury prevention have been reported.9 14 15 The RE-AIM framework16 17 was developed to enhance the translation of research into practice, and has been applied in such diverse fields as falls prevention,18 weight loss19 and mental health.20 Recently, an extension of the framework specific to the community sport context, the RE-AIM Sports Setting Matrix, has also been developed (table 1).14 The RE-AIM framework can be applied across all research phases, from planning and implementation, to reporting and reviewing.
However, there have been very few assessments of how RE-AIM has actually been used in any context. Recently, the RE-AIM Model Dimension Items Checklist (MDIC) was developed to assist the reviewing of project grant applications.21 This checklist comprises 31 items covering the five RE-AIM dimensions of Reach (4 items), Effectiveness (5 items), Adoption (8 items), Implementation (5 items) and Maintenance (9 items).16 21
1. WHO IS THE INTERVENTION TARGET? In the context of team ball sports, the end beneficiaries of any injury prevention efforts will be the players. However, players are not always directly targeted by researchers. An example is when researchers educate and train coaches to deliver a neuromuscular programme to their players. In such cases, there is a need to distinguish between the targeted health beneficiaries (the players), and the target of the researchers’ intervention (the coaches).
2. WHAT IS THE INTERVENTION? In the above example of educating and training coaches to deliver a neuromuscular programme to players, there are two levels of interaction taking place: one between researchers and coaches, and the other between coaches and their respective players
3. WHO DELIVERED THE INTERVENTION AND WERE THEY UNDER RESEARCHER CONTROL? The coaches who deliver an injuryprevention intervention to their players are ‘delivery agents’ in RE-AIM terms, and the RE-AIM MDIC dedicates an entire category to these individuals.
METHODS The Intervention Mapping (IM) health promotion programme planning protocol17 includes a step (Step 5) dedicated to planning programme translation. It comprises of seven tasks and is operationalised through six core processes (figure 1). IM Step 5 was used in this project to plan improved diffusion of the ARU MSP policy. When applying the IM protocol, it is important to distinguish between the programme (to be adopted and implemented) and the intervention (to facilitate programme adoption and implementation). In this project, the programme was defined as ‘training rugby players in the MSP’ and the intervention was ‘the planned activities undertaken to enhance the likelihood that rugby players would be trained in the MSP.
The project team identified the regional rugby association, regional rugby referees’ association, individual referees, club administrators, coaches and players as potential programme adopters and implementers. Coaches of senior rugby teams were identified as the primary focus of intervention activities because of their influence on player safety and training attitudes and behaviours and their role in training players in safety.
the project team did not actively engage with the range of potential programme adopters and implementers at various ecological or system levels until the end of task 5. This was because the identified people were nearly all volunteers with limited capacity to participate in this project and it was agreed that the most valuable contribution that they could make would be in tasks 6 and 7 (figure 1). Influential organisations (eg, regional rugby and referee associations) were informed of project progress and knew that they could actively participate in the later tasks. During task 2, the project focused on the individual, interpersonal and organisational ecological levels only (figure 2), as they related to coaches.
Programme use outcomes and programme adoption and implementation performance objectives were identified by asking “What do coaches need to do to constitute program adoption or adequate program implementation
?” The expected programme outcomes were that coaches would (1) decide to deliver MSP training to their players (adoption) and (2) actually deliver MSP training to their players (implementation). The specific performance objectives describing what coaches needed to do to adopt and implement the programme are listed in the left-hand columns of the matrixes in tables 3 and 4, respectively.
The determinants of coach programme adoption and implementation were specified by asking “What is likely to influence whether coaches adopt and implement the program?”
Specific programme adoption and implementation change objectives to be achieved by coaches are contained in the cells of tables 3 and 4, respectively. Conceptually, these represent a mechanism for creating changes in both the personal (eg, coach knowledge, skills and beliefs) and environmental factors that will influence coach behaviour.
Tasks 6 and 7
After the project team completed the programme adoption and implementation matrices, the advisory group—comprised of a Regional Rugby Union Association (RRUA) representative (employed administration officer), a Referees’ Board representative (also an active referee), a coach, a player and a club administrator—reviewed the matrices and approved the change objectives. They then brainstormed potential methods and strategies to facilitate coaches achieving the identified change objectives by asking: “What could be done to help, support or encourage coaches to achieve the agreed change objectives?” To ensure that the suggested strategies had some basis in evidence,
The Intervention Mapping (IM) protocol 5 can guide the development and appropriate targeting of health promotion programmes and has recently been used to plan some promising sports injury prevention interventions. 2 The IM protocol advocates for specifi c action to ensure successful development and implementation of evidence- and theoryinformed, context-specifi c interventions to maximise programme adoption, implementation and sustainability. There are seven IM protocol tasks involved in planning for adoption, implementation and sustainability — starting with identifying potential programme adopters and implementers and fi nishing with designing interventions for programme use, implementation and sustainability.
Management structures within sporting organisations could play a key role in facilitating the implementation of injury prevention interventions and safety programmes. 10 This is a key knowledge gap emphasised by the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) Sports Setting Matrix for sportsbased interventions, which highlights the range of infl uences on the uptake of interventions delivered through sport
There has been increasing recognition of the need for effectiveness research within the real-world intervention context of community sport.
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 effort