The FREED framework for community sports injury prevention implementation in New Zealand
The primary objective of the research underpinning this thesis has been to develop a framework that supports the implementation of community sports injury prevention programmes. Despite the wide acceptance of van Mechelen’s  widely accepted four-stage framework, known as the sequence of prevention, most research still focuses on his first two stages which address the incidence and causes/mechanics of injuries rather than the important third stage of implementing preventive measures. This thesis focuses on the implementation stage and proposes a new FREED framework for community sports injury prevention (Funding, Resources, Environment, Evaluation and Delivery). The FREED framework is the outcome of extensive analysis of the results of programmes implemented in New Zealand that have shown a decrease in the number and costs of injuries in a number of sports that have a strong community base.
A series of sport injury prevention programmes were developed, implemented, and assessed in cost-benefit terms for their effectiveness in changing behaviour and reducing injury counts and costs. The publications documenting the various programmes and methods of analyses are presented as chapters in this thesis. From lessons learnt during the research for each of the publications, themes were extracted and used to create the FREED framework. The FREED framework identifies key factors that have contributed to the success or failure of community sport injury prevention in New Zealand. In the final chapter, a case study of the application of the FREED framework to the New Zealand Rugby League injury prevention programme demonstrates the strengths and weakness of the approach in the real world of community sports. Development of a comprehensive framework for community sports injury prevention necessitated consideration of three thematic areas: 1) Specific sports (rugby union, football, netball); 2) Different participants (players, coaches, administrators), and 3) Injuries of different kinds from minor ones, such as dental, through to catastrophic ones such as spinal injury or concussion. The first New Zealand example of an effective injury prevention programme that took account of all of these was the 88% reduction in catastrophic spinal injuries from the scrum in rugby union. This followed the implementation of the scrum injury prevention programme in 2001. A more general sports concussion injury prevention programme resulted in a decrease in concussion claims for sports that the programme targeted (snow, horse and rugby) and a 66% decrease in the time players were waiting before seeking concussion treatment. The return on investment (ROI) in the rugby concussion programme alone was a minimum of $12.60 per dollar invested. This return on investment is reflective of the benefits, in fiscal terms of the reduction of injuries. Analysis of the effectiveness of injury prevention programmes in changing behaviour and reducing injury counts and costs in a range of community sports environments showed positive ROI ranging from $2.41 to $15.14 per dollar invested. A soccer programme, which did not interfere with how the game was played, resulted in a 2.5% decrease in the targeted knee and ankle injuries, and produced a ROI of $2.41. Rule changes to scrum engagements resulted in a 31% decrease in moderate to serious scrum neck and back injuries, producing a higher ROI. From the analysis of injury prevention in specific sports and for different participants, which comprises the substance of chapters 2-8 of the thesis, the FREED framework was developed to document key factors that contributed to the success or failure of community sports injury prevention in New Zealand. As previously outlined the FREED acronym takes the first letter of the five main factors: funding, resources, environments, evaluation and delivery. These are discussed in detail in chapter 9 where a case study of the application of the FREED framework to the New Zealand Rugby League injury prevention programme reveals its strengths and weakness in a real world community sports context. The five factors are highly interdependent but it is clear from the analyses in chapters 2-8 that adequate funding is crucial for there to be any effective significant return on investment in community sports injury prevention. At the community level there are limited opportunities, due to perception and control, to have people engaged with an injury prevention programme. It is the quality of the resources (financial, human - e.g. coaches, and services such as ACC), that allows for the prevention programme to continue past the testing and initial engagement stages. The importance of resources is emphasized throughout the discussions in chapters 2-8, most notably those dealing with concussion (chapters 5-7) and in chapter 8 on soccer and netball. These all show that resources supporting injury prevention were being used the following season. The FREED framework can be applied in communities across the country; it is not a framework that has been developed in a particular community or in a controlled experimental environment. The FREED framework is based on examples of the implementation of community sports injury prevention programmes in different parts of New Zealand. Community injury prevention is important if the field of sports injury prevention is to evolve. Most injuries occur in an environment of community sports. While the FREED framework was being developed, the field of community sports injury prevention was largely based on theory or limited case studies. Partly because of its comprehensive accident compensation insurance, New Zealand has been in an excellent position to trial various intervention approaches based on targeting specific injuries, specific sports, and specific groups. Drawing on these targeted practical examples, the FREED framework that focuses on implementation of injury prevention was developed. The Accident Compensation Commission, where the author works, was a critically important source of reliable data for many of the analyses that are reported in chapters 2-9 and the various conference presentations and posters.