Benets and Barriers Associated with Intention to Participate in Injury Prevention Programs in ROTC Cadets

Background: There is a lack of participation in Exercise-Related Injury Prevention Programs (ERIPPs) within Reserve Ocer Training Corps (ROTC) which limits the effectiveness. Identication of factors which may inuence participation in ERIPPs within ROTC cadets is an important rst step in improving adoption and adherence rates. Therefore, the purpose of the study was to identify factors associated with intention to participate in an ERIPP within ROTC cadets. Methods: The study design was cross-sectional where a paper survey was distributed in spring 2019. Twenty-eight (M/F=23/5; Age=20.68±2.02years; Height=175.78±8.95cm; Mass=75.30±11.10kg) ROTC cadets volunteered to participate in this study. Participants completed the Health Belief Model Scale (HBMS) and Theory of Planned Behavior Scale (TPBS) to assess attitudes towards participation in ERIPPs. A backwards multiple linear regression was used to determine if associations between attitudes towards ERIPP participation and intention to participate existed. Partial eta squared was calculated for each signicant variable to determine the strength of the association and alpha was set at P ≤ 0.05 for all analyses. Results: Perceived benets (B=4.364, (cid:0) 2 =0.68, p<0.001) had a positive and large association with intention to participate while perceived barriers (B=-2.43, (cid:0) 2 =0.40, p<0.001) had a negative and large association with intention to participate. There were no other statistically signicant associations (p>0.05). Conclusion: Perceived benets and barriers were signicantly associated with intention to participate in ERIPPs within ROTC cadets. Implementation strategies for ERIPPs may need to focus on the benets and barriers of participating in an ERIPP to increase adoption and adherence.


Background
Lower extremity injuries are common in the physically active population including those participating in the military (1)(2)(3). Military personnel suffer musculoskeletal injuries in the knee and ankle very similarly to individuals who participate in physical and sporting activities (4). From 1998 to 2006, over 423,000 service members sustained an ankle sprain injury at a rate of 34.95 per 1,000 person-years (1). In comparison, from 1998-2004, 27,117 ankle sprains occurred within collegiate athletes at a rate of 0.83 per 1,000 exposures (5). Additionally, from 1998-2003 over 70,000 members of the military sustained an injury to the anterior cruciate ligament of the knee (2) while 4,800 injuries occurred within collegiate athletes at a rate of 0.15 per 1,000 exposures between 1998-2004 (5). The consequences of these injuries are signi cant in the short-and long-term. Some of the short-term consequences include pain, loss of function, and missed duty (6). In the long-term, there is an increased likelihood for the early development of osteoarthritis (7) and decreased health-related quality of life (8). Focus has been shifted to prevention of these injuries to avoid the negative consequences associated with them.
In 2003, a military based group was established to investigate different methods of injury prevention and make recommendations for military personnel (9). They determined the four critical components to effective injury prevention were education, leader support, surveillance, and research to support the effectiveness. Furthermore, six methods of injury prevention were found that met all criteria and were recommended to all portions of the military. One of the six methods was exercise-related injury prevention programs (ERIPPs) (9). ERIPPs are designed to prevent musculoskeletal injuries using balance, strength, range of motion, and agility exercises. Several ERIPPs have demonstrated e cacy to reduce the risk of lower extremity injuries and improve functional performance of participants in sporting and military populations (10)(11)(12). However, one of the major limitations of the effectiveness of these programs is the adoption and subsequent adherence to completing the exercises as prescribed by users (13,14).
One major step in starting to improve adherence rates is to gain a better understanding of the reasons behind the lack of adoption and adherence. Several studies have begun to use social and behavioral theoretical models and frameworks to better understand the uptake of preventative health behaviors (15)(16)(17)(18). The two most commonly used theories are the Health Belief Model (HBM) and Theory of Planned Behavior (TPB). The HBM contains six theoretical constructs (perceived susceptibility, perceived severity, perceived bene ts, perceived barriers, cues to action, self-e cacy) that are thought to directly predict participation in a preventative health behavior (19). The TPB contains three theoretical constructs (attitudes, perceived subjective norms, perceived behavioral control) which are thought to indirectly predict participation in a preventative health behavior through intention to participate (20). There is a lack of current literature investigating attitudes towards participating in ERIPPs within military personnel and speci cally ROTC cadets. Identi cation of the most in uential factors could enhance the development of implementation strategies for ERIPPs within this population. Therefore, the purpose of this study was to identify factors associated with intention to participate in an ERIPP within Reserve O cer Training Corps (ROTC) cadets.

Methods
A cross-sectional research design was implemented which involved participants completing paper surveys on one occasion in spring 2018. Participants completed a demographic questionnaire, Health Belief Model Scale (HBMS) (21) and Theory of Planned Behavior Scale (TPBS) (21). This study was approved by the Institutional Review Board.
Participants were recruited during ROTC courses at a single university. Twenty-eight ROTC cadets volunteered to participate in this study during the spring semester (Table 1). Participants were included if they were over the age of 18 and reported being physically active. Physically active was de ned as participating in a moderate level of physical activity for at least 90 minutes per week. The primary investigator explained the study and went over the consent forms with the participants. Once the participant provided written informed consent, survey packets were distributed. The HBMS was developed in a prior study (22) and an exploratory factor analysis con rmed the psychometric properties of the HBMS with all nine subscales having acceptable internal consistency values (Cronbach's alpha > 0.80) (21). The nalized version of the HBMS contained nine subscales (perceived susceptibility, perceived bene ts, general health cues, perceived barriers, perceived consequences, fear of injury, community led self-e cacy, individual self-e cacy, and external health cues) comprised of a total of 39 items to assess attitudes towards ERIPP participation. The response choices ranged along a 7-point Likert scale from strongly agree to strongly disagree. Positive scores indicated positive attitudes for all subscales except for perceived barriers where a positive score meant they perceived more barriers.
The TPBS was developed in another study (22) to assess attitudes towards participation in ERIPPs. An exploratory factor analysis con rmed the psychometric properties of the TPBS with all ve subscales having acceptable internal consistency values (Cronbach's alpha > 0.77) (21). The nalized version of the TPBS contained ve subscales (perceived bene ts, perceived social norms, perceived barriers, and perceived social in uence, intention to participate) derived from a total of 19 items used to assess attitudes towards ERIPP participation. The response choices ranged along a 7-point Likert scale from strongly agree to strongly disagree. Positive scores indicated positive attitudes for all subscales except perceived barriers where a positive score would mean they perceived more barriers.
Scale data was scanned using Remark O ce OMR (Gravic Inc, Version 10.3; Malvern, PA) and entered into a spreadsheet. Participants who were missing more than 10% of the scale data were excluded from analysis. When participants were missing less than 10% of scale data, multiple imputation was used to estimate missing data points (SPSS Version 25). The independent variables were the subscales of the HBMS and TPBS and the dependent variable was intention to participate in an ERIPP. The intention to participate variable was calculated using total scores of the intention subscale of the TPBS. Total scores and associated median and interquartile ranges were calculated for each of the HBMS and TPBS

Discussion
The primary ndings of this study were the signi cant associations between perceived bene ts and barriers and intention to participate in an ERIPP in ROTC cadets. Additionally, it is important to note that social in uence was trending towards statistical signi cance and had a large association with intention to participate in an ERIPP (B = 2.22, 2 =0.23, p = 0.08). These results indicate ROTC cadets value bene ts of ERIPP participation, barriers to participate in ERIPPs, and social in uences.
The two factors most associated with intention to participate in ERIPPs were perceived bene ts of participation and perceived barriers to participation. Perceived bene ts of participation include anything that an individual sees as gaining from their participation in an ERIPP such as reducing lower extremity injury rate, improving functional performance, and increasing knowledge of lower extremity injuries and ERIPPs. Perceived barriers include anything the individual sees as a barrier to their participation in an ERIPP. As cadets indicated that they perceived more bene ts of participation and reduced challenges to their participation they were more likely to indicate enhanced levels of intention to participate in an ERIPP.
These results align well with the results of a study (15) which investigated attitudes towards participation in ERIPPs within female netball players. There was a signi cant association between the attitudes subscale, comprised of questions related to barriers and bene ts of participation, and intention to participate (15). There are multiple bene ts to participating in ERIPPs within military personnel including reduction in the risk of lower extremity injury (24) and improvements in functional performance (11,25).
Some of the proposed barriers to participation in ERIPPs have been time, availability of equipment, location of the program, and knowledge on how to perform the exercises (17,26). Bene ts to participation and strategies to overcome barriers may be in uential to ROTC cadets when choosing to adopt ERIPPs.
The association between social in uence and intention to participate was trending towards signi cance and was associated with a large partial eta squared effect size. The social in uence subscale focuses on the in uence of peer participation in an ERIPP and the importance of data to support the effectiveness of the ERIPP to improve athletic performance. Some literature has suggested that ERIPPs can not only reduce the risk of injury, but also lead to improvements in functional performance (11,25). Speci cally, one study indicated improvements following participation in the Dynamic Integrated Movement Enhancement program in jump landing technique (11) while another found improvements in the Army Physical Fitness Test including the 2 mile run, push-up, and sit-up performance (25). However, it is unlikely that ERIPP participants are aware of the bene ts of participation speci c to improvements in performance. These speci c bene ts could be highly motivating as ROTC cadets have requirements to pass the Army Physical Fitness Test, which requires a signi cant amount of physical performance.
Additionally, the importance of group setting is already a factor that is instrumental in most military activities (27). The information gained in this study further supports the need for the ERIPP to be a part of normal physical tness that is completed as a group rather than something the cadet is expected to do individually. The introduction of the speci c data that shows improvements in physical performance after participation in an ERIPP and including the ERIPP in regularly scheduled group physical tness sessions may encourage ROTC cadets to participate.
There were several subscales from the HBMS and TPBS that were not signi cantly associated with intention to participate. A few of the subscales with a lack of association with intention were HBMS perceived susceptibility, HBMS fear of injury, and HBMS perceived consequences. The participants in this study were young, healthy individuals and therefore may have not perceived susceptibility to injury, fear of injury, and consequences because most of them had probably not suffered a signi cant injury in the past. Although most of the participants had experienced an injury in the past, only 14% had an injury they classi ed as "severe". This assortation is supported by the literature that indicates that this population reports relatively low levels of perceived probability and worry/concern of injury as well as con dence in their ability to avoid injury (28). Additionally, soldiers have indicated that there is a lack of injury education in the military which could lead to a lack of realization of susceptibility and consequences of injury (29). There is a need to further investigate these variables and their importance in relation to participation in ERIPPs in other populations.
The results of this study indicate implementation plans for ERIPPs within ROTC cadets should place a focus on bene ts, barriers, and social in uence. Participants could be educated on the bene ts of participating in ERIPPs including the reduction in lower extremity injuries and improvements in functional performance. Additionally, educational information could be provided on common barriers to participating and strategies to overcome those barriers. Lastly, social in uence could be targeted by providing a group setting for the cadets to participate in. Including focus on these factors within the implementation plan for ERIPPs may lead to increased adoption and adherence of these programs.
Therefore, future research is needed to determine the effectiveness of an intervention which targets these factors to improve adherence rates of ERIPPs.
There were several limitations associated with this study. Intention to participate in an ERIPP was used as the dependent variable for the regression analysis. There is currently a lack of data to suggest whether intention to participate is directly related to actual participation within users of the program. There is some evidence to suggest that intention to implement ERIPPs is not associated with actual implementation in coaches (30). The sample size for the study was limited and only contained ROTC cadets from one university. As a result, the ndings of this study may not be generalized to other military personnel. Participation in an ERIPP is a multifactorial issue. For the purposes of this study, only the attitudes of the user were taken into consideration. It is likely the attitudes towards injury prevention of the leaders are an important factor and must be investigated through future research.

Conclusion
Bene ts and barriers were signi cantly associated with intention to participate in ERIPPs within ROTC cadets. Implementation strategies should focus on presenting the bene ts and barriers of ERIPP participation to the users. Future research is necessary to determine if interventions focused on bene ts and barriers will lead to actual improvements in participation. Availability of data and materials

Abbreviations
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.