Tackling Rugby Injury: lessons learned from the implementation of a five-year sports Injury prevention program

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1 Tackling Rugby Injury: lessons learned from the implementation of a five-year sports Injury prevention program DJ Chalmers 1, JC Simpson I & R Depree 2 1.Injury Prevention Research Unit, Department Of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, New Zealand. 2Accident Compensation Corporation, New Zealand. Rugby Union football is a very popular sport in New Zealand but of all the major sports played in that country, it has the highest reported incidence of injury. In 1995, a national rugby injury prevention program was instigated to address this problem. Known as Tackling Rugby Injury, this multifaceted program was implemented over a five-year period. The program was based on the results of a prospective cohort study of rugby injury, known as the Rugby Injury and Performance Project (RIPP), and was organised around seven themes, five relating to the prevention of injury: coaching, fitness, injury management, tackling, and foul play, and two relating to the implementation and evaluation of the program. The purpose of this paper is to describe the lessons learned from the implementation of Tackling Rugby Injury. Qualitative research methods were used to describe the process of implementation, including informant interviews, participant observation, and the scrutiny of written, visual and archival material. Among the lessons learned were the importance of basing injury prevention strategies on scientific evidence rather than popular belief, the difficulty in implementing complex interventions, the advantages of a formal agreement between parmers in the implementation of a program, the central role played by coaches in promoting injury prevention strategies, and the value of describing the process of implementation as well as monitoring injury outcomes and changes in knowledge, attitudes and behaviour. It is hoped that other sports wishing to develop injury prevention programs can learn from this experience. J Sci Med Sport;7:1:74-84, Introduction Rugby Union football is a very popular sport in New Zealand and is considered by many to' be the national sport. Of all the major sports played in New Zealand, however, rugby has the highest reported incidence of injury 1. In 1995, a national rugby injury prevention program was instigated to address this problem. Known as 'Tackling Rugby Injury', this multifaceted program was implemented over a five-year period and was the result of a collaboration between injury prevention researchers, rugby administrators, coaches and referees, and experts in physical education, sports medicine and injury prevention 2. The program was based on preliminary results from a prospective cohort study of rugby injury, the Rugby Injury and Performance Project (RIPP), undertaken at the University of Otago in s. The development and content of Tackling Rugby Injury has been described in detail by Simpson, Chalmers, and Waller 2. The program was organised around 74

2 seven themes, five relating to the prevention of injury: coaching, fitness, injury management, tackling, and foul play, and two relating to the implementation and evaluation of the program. The first step in implementing the program was to set up a panel of stakeholders, comprising representatives of the New Zealand Rugby Football Union (NZRFU), the Accident Compensation Corporation (ACC), (1) Sports Medicine New Zealand, the Hillary Commission for Sport, Fitness and Leisure, and the Injury Prevention Research Unit (IPRU). Known as the Tackling Rugby Injury Panel (TRIP), this group was responsible for overseeing implementation of the programme and met regularly throughout the five years of implementation. Not all strategies in the program were implemented (or implemented as planned) and additional strategies were added as implementation proceeded. Table 1 provides examples of key strategies implemented, including some of the additional strategies. Rigorous evaluation of the implementation of Tackling Rugby Injury was an essential part of the program, both to determine ff it had contributed to a reduction in the incidence and seventy of rugby injury in New Zealand and to document the process of implementation 2. In 1995, ACC commissioned the IPRU to undertake an evaluation of implementation of the program. This had three objectives: 1. To monitor the incidence, nature and circumstances of injury. 2. To monitor the knowledge, attitudes and behaviour of players. 3. To describe the process and impact of implementation of the program. Coaching 1. Written and video resources were produced by ACC and NZRFU, and existing coaching manuals were expanded to include information on injury prevention. 2. Compulsory injury prevention seminars were introduced for coaches in initially, these focussed on scrum safety but the range of topics was subsequently expanded to include other safety issues.* Fitness 3. Television advertising campaigns were used to raise the profile of the program, initially, these emphasised off-season fitness training.* 4. Publication of pre-season fitness training guides for players.* Management of injury 5. A series of review articles on the effectiveness of protective equipment in rugby was commissioned by ACC and published in The wearing of mouthguards was made compulsory for lower grades in 1997, and for all grades in Guidelines on responsible alcohol use were included in the various resource documents and a brochure on alcohol and sport was published by the Alcohol Advisory Council 17. Tackle 8. An investigation of tackle injuries was undertaken 9 and improved tackling techniques were promoted through the coaching seminars and resource materials. Foul play 9. Referees increased their enforcement of the rules relating to foul play. * Additional strategy. Table 1: Key strategies implemented during the period

3 Tackling rugby injury: Lessons learned from the implementation.,. The incidence, nature and circumstances of injury were monitored by means of national telephone surveys of randomly selected male club players, conducted in 1997 and 1998 (Unpublished report: J. Simpson, L. Miles, D. Chalmers. Evaluation of Tackling Rugby Injury: Final report to ACC, 2000). The incidence of injury over these two years was 5.4 injuries per 100 player games, which was half the rate of 10.9 injuries per 100 player games recorded for male players in RIPP in Dunedin clubs in The knowledge, attitudes and behaviour of players were monitored by means of national surveys of randomly selected players, conducted in 1996 and 1999 (Unpublished report: J. Simpson, L. Miles, D. Chalmers. Evaluation of Tackling Rugby Injury: Final report to ACC, 2000). While there was little evidence of change over this period, one notable finding was that of a substantial increase in the number of players who reported always wearing a mouthguard when playing, from 56% in 1996 to 76% in The purpose of this paper is to describe the lessons learned from the implementation of Tackling Rugby Injury. The focus will thus be on the process of implementation. Getting started 1. Base program on scientific evidence. 2. Design the program as a series of achievable steps. 3. Time the introduction of the program to: (a) maximise the support of stakeholders (b) allow sufficient time for organisational acceptance. Working in partnership 4. Allow sufficient time and resources for partnerships to develop. 5. Recognise the different contributions of partners. 6. Reassess roles and responsibilities within partnerships regularly. 7. Have a formal agreement, regarding the functioning of the partnership. 8. Consider establishing a lead agency. 9. Gain commitment from agencies outside the key stakeholder group. 10. Write the program into strategic/business plans of stakeholders. 11. Prioritise objectives and strategies. 12. Employ injury prevention or health promotion experts to manage implementation. 13. Ensure that organisational objectives, outside of reducing injury, are made explicit. Successful strategies 14. Rule changes are an acceptable option. 15. Assess rule changes for their effect on injury. 16. Acknowledge the importance of coaches. 17. Build on existing infrastructure. 18. Capitalise on external influences. 19. Develop concept's and a language that have meaning for stakeholders. 20. Highlight the as.(;ociation between injury and performance Evaluation 21. Ensure that injury reporting systems are not vulnerable to organisational change. 22. Budget for the cost of monitoring injury, knowledge, attitudes and behaviour. 23. Describe the process of implementation. Table 2: Summary of lessons learned in the implementation and evaluation of Tackling Rugby Injury. 76

4 Method Qualitative research methods were used to describe the process and impact of implementation. These included informant interviews, participant observation, and the scrutiny of written, visual and archival material (e.g. reports, resource materials, meeting minutes). A total of 106 informant interviews were conducted between December 1995 and June The interviewees were drawn from organisations involved in RIPP and in developing and implementing Tackling Rugby Injury. They included rugby development officers, coaches, referees, club officials, players, first aid providers, media personnel, ACC staff and NZRFU personnel. Interviewees were selected from throughout New Zealand, including urban and rural areas, and from provinces in all three divisions of the New Zealand interprovincial rugby competition. Open-ended questions were used to elicit comment from the interviewees on the state of rugby, their understanding and experience of the national injury prevention program, and other pertinent issues. Results and DiSCuSSiOn Tackling Rugby Injury was a complex and ambitious program that was implemented over a five-year period from 1995 to A number of important lessons were learned from its development and implementation. These are presented under four headings: getting started, working in partnership, successful strategies and evaluation. A summary of the lessons learned is presented in Table 2. Getting started Research base Preliminary findings from RIPP provided the scientific basis for the development of Tackling Rugby Injury 2. The time-frame imposed by the funding arrangements for development and implementation of the program, and the enthusiasm of the NZRFU to capitalise on the impetus engendered by the research, made it necessary to formulate the recommendations and strategies making up the program before more detailed findings were available. While Tackling Rugby Injury was based predominantly on preliminary findings from RIPP, what was finally implemented wasn't necessarily so. There were a number of reasons for this. In some cases, for instance, popular belief won out over scientific evidence. For example, evidence relating off-season training to injury reduction was equivocal and a call for further research was made in the program. Despite this, off-season training played a prominent role in the early stages of implementation. While decisions have to be made on the basis of the evidence available, caution needs to be exercised before committing substantial resources to measures that are unproven. Similarly, it is doubtful if committing resources to the promotion of already entrenched practices will achieve a measurable reduction in injury. Warming-up was already common practice among players before the implementation of Tackling Rugby Injury and while the necessity for warming-up was not in question, the need to promote it was. Nevertheless, it provided a convenient link to existing practice and may have assisted in promoting the program overall. Program design The program set out in Tackling Rugby Injury focussed on changing environ- 77

5 ments, policies, systems and practices, rather than simply targeting the behaviour of individuals. The main stakeholders, however, had no previous experience of implementing such strategies and were unprepared for the complexity and size of the task. One lesson learned from this was that strategies require time and expertise to implement, and are best presented as a series of clearly defined and achievable steps. Some of the more easily implemented strategies involved only a single action, such as a policy change. An example of this was the introduction of compulsory mouthguard wearing, which affirmed what was already common practice. Although the majority of players usually wore mouthguards when playing, instituting mandatory wearing took time to achieve due to resistance initially by the NZRFU Council. Once agreed, however, compulsory wearing was introduced progressively over two seasons. Also relatively easy to implement were strategies that involved the grafting of measures onto existing systems or practices. An example of this was the inclusion of injury prevention modules in existing training courses for coaches. As the NZRFU Director of Coaching, who had been actively involved in the development of Tackling Rugby Injury, supported this, it was readily accepted in principle. Developing materials to be incorporated into the training courses, however, took some time. The Director of Coaching developed the materials, in consultation with injury prevention and exercise prescription advisors, the existing training manuals were then revised and, finally, the NZRFU staff members responsible for presenting the courses were given training on the content of the new modules. Not all of the changes required to reduce injury in the longer term could be addressed this simply. Some required advocacy skills, time and persistence to achieve. A proposal that sports first aid courses be provided to address the lack of people trained to undertake on-field assessment of injury at lower grade club and school games was one such strategy. It required the co-operation of a number of organisations and consensus over what constituted an appropriate course. This strategy had not been achieved by the conclusion of implementation in The most difficult strategies to implement were those aimed at changing the attitudes of the wider community toward injuries and injury prevention. One such strategy involved encouraging the media to convey positive messages regarding the appropriate treatment of injury and to reinforce the actions of players who behaved appropriately when injured. Although some success was achieved, gaining access to members of the media for this purpose was surprisingly difficult. Timing Many health promotion programs are developed and implemented, regardless of whether the time is right to do so. It was fortunate that in 1992, when it was proposed that RIPP be undertaken, the interests of the NZRFU, ACC and IPRU coincided. The NZRFU was concerned about the impact of injury on team performance and the image of the game, ACC was concerned about the frequency and cost of claims for rugby injury, and the IPRU was interested in applying epidemiological research methods to the investigation of injury in sport. It was this conjunction of interests that drove the research and later 78

6 drove the development of the program. Having made an investment in the research and in the development of the program, the key stakeholders were then committed to following through with the implementation of Tackling Rugby Injury. Timing was also an issue when it came to negotiating implementation of the program with administrators of the key stake-holding organisations. While ACC and the NZRFU supported Tackling Rugby Injury in principle, it took almost a year for the detail of the program to be accepted by the senior management and boards of the two organisations, and for resources to be committed for its implementation. Sufficient time must be allowed for such negotiation. In hindsight, the agreed time frame for commencing the implementation of Tackling Rugby Injury was overly optimistic. Working in partnership The involvement of stakeholders in the process of planning and implementing the program was necessary if it was to be a success. When the program was developed, it was recognised that no single organisation had the skills, experience or mandate to achieve the changes required to bring about the desired reduction in injury. As a result, building a partnership between the stakeholders was proposed. Establishment and maintenance of the partnership The overall success of Tackling Rugby Injury suggested that TRIP, the group formed to oversee implementation of the program, functioned effectively as a partnership. Difficulties were encountered, however, with one example being that of accommodating differences between a corporation with paid employees (ACC) and a sporting body that, until its very recent past, had been governed and run largely by volunteers (NZRFU). This required a process that allowed assumptions held by each to be challenged, but also demanded some compromise between parties. To be effective, partnerships require time for the building of trust and respect between parties. Roles, responsibilities and relationships Partnerships require a sense of equality to flourish, and not all contributions can be measured in financial terms. Within TRIP, ACC provided substantial funding for both the development and implementation of the program. Implementation of the program could not have proceeded, however, without the endorsement and human resources of the NZRFU. The contributions of the minor partners were generally less tangible, and not fully utilised in the implementation of Tackling Rugby Injury. Partnerships do not remain static and roles and responsibilities should be open to negotiation and change. The roles and relationships of the stakeholders in Tackling Rugby Injury evolved over time. For example, a more direct and mutually supportive relationship developed between ACC and the NZRFU as the implementation progressed. Formal agreement It was intended that the individual members of TRIP would report on the progress being made by their respective organisations, toward implementation of the program, and thus be accountable to each other. Collectively, the panel 79

7 was expected to monitor overall progress on implementation of the program, perform a peer review role, and plan and facilitate the introduction of new initiatives. While these roles were agreed at the first meeting of TRIP, along with the administrative arrangements for the panel, there was no formalised agreement between members. An agreement, signed by all partners, setting out the function of the panel, the roles and responsibilities of members and the availability of resources, would have been useful at times when representation on the panel changed or the functioning of the panel came under scrutiny. Lead agency While it might have been hoped that the NZRFU could voluntarily take ownership of the program from the outset, this was acknowledged to be an unrealistic expectation in the short term. Neither it, nor any other organisation, had the skills, experience or mandate to take the lead in implementing a program designed to operate collaboratively. The notion of working in partnership was intended, therefore, to avoid having one agency in control of the whole program. It would have been preferable to have had a single agency with the mandate, resources and skills to lead the implementation and ensure coordination and accountability were actively managed. Other organisations A number of strategies were dependent for their success on the actions of parties outside of those represented on TRIP. While some of these strategies were successful, others were not implemented or were only partially implemented. For these, more time and effort was needed by the major stakeholders to secure the commitment of the parties involved. A common characteristic of these strategies was that they involved long-term solutions to injury problems, such as the proposed provision of courses in sports first aid mentioned earlier. Ensuring continuation Programs are less vulnerable to organisational change if they are included in strategic and/or business plans and are not dependent on specific individuals for their implementation. Both major stakeholders underwent major organisational change early on in the implementation period, with the result that strategies from Tackling Rugby Injury were not written into the strategic or business plans of either organisation. At critical times during the five-year implementation period, personnel changes occurred in both ACC and NZRFU. While it is inevitable that changes in personnel will occur over long periods of program.implementation, much institutional history from the developmental stages of Tackling Rugby Injury was lost when this occurred. Setting priorities Tackling Rugby Injury had many objectives and strategies. As it was not foreseen that those who developed the program would not also be responsible for its implementation, no guidance was provided on the interdependence of strategies, whether these were intended to address short or long term change, and the consequences for the program as a whole of omitting certain of them. This proved to be an unfortunate oversight. Identifying the relative importance of each strategy during its development would have contributed to a better understanding of the overall intention of the program when it came to be implemented. 80

8 Expertise While ACC had experience in managing injury prevention programs, it was inexperienced in working collaboratively with sporting organisations. For the NZRFU, practising injury prevention using public health strategies was a new concept and one for which it had neither the expertise nor the experience. It was proposed during the development of Tackling Rugby Injury that an injury prevention position be established within the NZRFU but this was not considered viable at the time. One outcome of implementation of the program, however, was the establishment in 2000 of an injury prevention management position within the NZRFU, with funding support from ACC. The establishment of such a position at the outset would have been beneficial for implementation of the program. Other objectives The objectives of organisations, outside those of reducing injury, need to be made explicit and allowed for in the development of an injury prevention program. For example, improving safety may help achieve the objective of attracting more participants to the sport. Meeting such objectives may provide the incentive needed by an organisation to adopt and implement an injury prevention program. Making such organisational objectives explicit should ensure that any that are in conflict with the goals of injury prevention can be recognised and addressed, and make uptake of the program within an organisation easier. Successful strategies Following are examples of successful strategies, taken from the development and implementation of the Tackling Rugby Injury program. Rule changes Rational and realistic rule changes are an acceptable option for injury prevention. A condition of the NZRFU's involvement in the development of Tackling Rugby Injury was that the program should not require rule changes that would alter the nature of the game. The acceptance in 1996 of the recommendation that mouthguard weaiing in games be made compulsory - requiring a domestic law change - saw a reduction in the number of dental injury claims made to ACC. While this recommendation was at first resisted by the NZRFU Council, key factors influencing its eventual acceptance were that the NZRFU was no longer dealing with major crises or reorganisation, and the promotion of the strategy was undertaken by people trusted and respected by the sport's governing body. Rule changes are sometimes made in sport to address deficient aspects of the game or to increase spectator interest. Such changes need to be evaluated for their effect on injury, and should not unwittingly place players at increased risk. When Tackling Rugby Injury was being developed it was known from RIPP that 40% of injuries occurred in tackles and also that changes had recently been made to the laws relating to this phase of play. An investigation of tacklerelated injuries was instituted to address this issue 9. Recommendations for improving tackling technique were then promoted through coaching seminars and resource materials. A key factor in the success of this strategy was to involve recognised experts in the investigation, whose opinions would be 81

9 respected by the sport. Ideally, rule changes should be piloted with sub-sets of players before introducing them to the whole sport, and administrators should be prepared to reverse changes if safety is compromised. Coaches Considerable resources were chalmelled towards coaches, with the development of visually interesting and well presented training materials, the instigation of compulsory safety seminars, and the establishment of a system for the ongoing communication of injury prevention information (i.e. coach data base and newsletter). All of these strategies contributed toward increasing the profile of injury prevention in the sport as a whole and increasing the knowledge and skills of coaches with regard to injury prevention. A key factor in the success of this strategy was recognising and valuing the role of coaches as part of the injury prevention team, from an early stage in the development of Tackling Rugby Injury. Management of foul play Success can be achieved by building on an existing infrastructure. In Tackling Rugby Injury, two complementary approaches were taken with respect to reducing injury from foul play. One was the endorsement of the existing judiciary's role in penalising foul play. While outside the influence of the program, it was important to acknowledge the contribution to injury prevention of this existing strategy. The second approach was to capitalise on an existing infrastructure. Referees were well represented on the team that developed Tackling Rugby Injury. The program was used to extend those activities which these representatives wished to develop to reduce foul play, by arguing the benefits that these could have for injury prevention. As a result, game management by referees took greater account of the safety of players, and it was also better supported by the administration. Responding to external influences External influences can be used to advance the objectives of an injury prevention program. During the development of Tackling Rugby Injury, the introduction of compulsory injury prevention training for coaches was proposed. At the time this was thought to be both impracticable and unenforceable, because a further imposition on the time of volunteers might impede their recruitment and retention as coaches. In 1996, however, the results of a study of spinal injury to rugby players were published (1 ). The investigators expressed their concern publicly at the high and apparently increasing incidence of these injuries in rugby and called for the NZRFU to act. As a result, compulsory safety seminars for coaches were introduced and provided a significant and welcome addition to the program. One lesson learned from this experience was that good strategies shouldn't be abandoned if they aren't initially accepted, as changing circumstances may permit their resurrection. The second lesson learned was to maintain sufficient flexibility to capitalise on opportunities that may subsequently arise to achieve the aims and objectives of the program. Development of concepts and a language Injury prevention gained a positive profile in the rugby community during the five years in which Tackling Rugby Injury was implemented. One important but 82

10 unplanned factor was the development of concepts and a language that the NZRFU and other stakeholders could use to describe their commitment to injury prevention. For example, when the NZRFU was publicly criticised in 1996 with regard to spinal cord injury it had been unable to respond with evidence of a commitment to injury prevention. When the issue arose again in 2000, the NZRFU had the language with which to respond immediately, acknowledging the problem and publicly drawing attention to its injury prevention program. When RIPP was being undertaken, it was argued that injury prevention was beneficial to individual and team performance. That is, by reducing the incidence of injury players and teams can perform to their full potential. This concept underpilmed the development of Tackling Rugby Injury and provided the NZRFU with a strong rationale for promoting injury prevention in rugby. Evaluation As noted in the introduction, rigorous evaluation of the implementation of the program was considered essential. The goal of most sports injury prevention programs is to reduce the incidence of injury. Having a reliable means of measuring the incidence over time is therefore essential. For the evaluation of Tackling Rugby Injury, it was intended to conduct annual, national telephone surveys with players randomly sampled from one of two national databases. The ability to do this was compromised by events beyond the control of the evaluators, although sufficient data were collected to provide useful information for measuring the outcome of the program. One lesson learned from this experience was that in developing sports injury reporting systems, care should be taken to ensure that they are not vulnerable to changes in the policies and practices of either the sport or external agencies. Another lesson learned was that the cost of injury reporting systems can be high and that this cost needs to be included in the budget for implementation of a program. The multifaceted and dynamic nature of Tackling Rugby Injury made the task of evaluating its implementation a challenge. In addition to monitoring the incidence of injury and player attitudes, knowledge and behaviour, it was essential to describe the process of implementation. This involved recording what actually happened, rather than assuming that strategies were implemented as planned. It also provided a valuable record of the changing environment in which the program was being implemented. conclusion The preceding sections have described key lessons learned in the development, implementation and evaluation of the Tackling Rugby Injury program. It is hoped that other sports wishing to develop injury prevention programs can learn from this experience. Acknowledgements This paper was adapted from a report commissioned by the Accident Compensation Corporation (ACC). The Injury Prevention Research Unit is funded by ACC and the Health Research Council of New Zealand (HRC}. Footnotes (1) Accident Compensation Corporation (ACC): administrator of New Zealand's national, 83

11 Tackling rugl~y injury: Lessons learned from the implementation... comprehensive, no-fault injury compensation scheme. References 1. Hume PA, Marshall SW. Sports injuries in New Zealand: Exploratory analyses. NZ J Sports Med 1994;22: Simpson J, Chalmers D and Wailer A. The New Zealand Rugby Injury and Performance Project: Developing q'ackling Rugby Injury', a national injury prevention programme. Health Promotion Journal of Australia 2002;13: Waller AE, Feehan M, Marshall SW, et al. The New Zealand Rugby Injury and Performance Project: I. Design and methodology of a prospective follow-up study. Br J Sports Med 1994;28: Gerrard DF, Waller AE, Bird YN. The New Zealand Rugby Injury and Performance Project: II. Previous injury experience of a rugby-playing cohort. Br J Sports Med 1994;28: QualTie KL, Feeban AE, Waller M, et al. The New Zealand rugby injury and performance project: alcohol use patterns within a cohort of rugby players. Addiction 1996;91: Bird YN, Waller AE, Marshall SW, et al. The New Zealand Rugby Injury and Performance Project: V. Epidemiology of a season of rugby injury. Br J Sports Med 1998;32: Alsop JC, Chalmers DJ, Williams SM, et al. Temporal patterns of injury during a rugby season. J Sci Med Sport 2000;3: Quarrie KL, Alsop JC, Waller AE, et al. The New Zealand rugby injury and performance project: VI. A prospective cohort study of risk factors for injury in rugby union football. Br J Sports Med 2001 ;35: Wilson BD, Quarrie KL, Milburn PD, et al. The nature and circumstances of tackle injuries in rugby. Aus J Sci Med Sport 1999;2: Armour K, Clatworthy BJ, Bean AR, et al. Spinal injuries in New Zealand rugby and rugby league - a twenty year survey. NZ Med J 1997;1057: Chalmers DJ. Mouthguards: protection for the mouth in rugby union. Sports Med 1998;25:5: Gerrard DF. External knee support in Rugby Union: Effectiveness of bracing and taping. Sports Med 1998;25: Gerrard DF. The use of padding in Rugby Union: An overview. Sports Med 1998;25: Hume PA, Gerrard DF. Effectiveness of ankle support: Bracing and taping in Rugby Union. Sports Med 1998;25: Milburn PD, Barry EB. Shoe-surface interaction and the reduction of injury in Rugby Union. Sports Med 1998;25: Wilson BD. Protective headgear in Rugby Union. Sports Med 1998;25: ALAC. What difference can a couple of drinks make? Wellington. Alcohol Advisory Council of New Zealand. Undated. 84

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