Use of Social or Behavioral Theories in Exercise-Related Injury Prevention Program Research: A Systematic Review

Attitudes Toward Injury-Prevention Program Participation Based on Race and Collegiate Division in Female Athletes

CONTEXT

Injury-prevention programs (IPPs) have been effective in reducing lower extremity injury rates, but user compliance plays a major role in their effectiveness. Race and collegiate division may affect attitudes toward participation in IPPs and compliance in female collegiate athletes.

OBJECTIVE

To compare attitudes toward IPPs based on race and collegiate division.

DESIGN

Cross-sectional study.

SETTING

Survey.

PATIENTS OR OTHER PARTICIPANTS

A total of 118 female collegiate athletes (age = 19.71 ± 1.47 years, height = 169.46 ± 9.09 cm, mass = 69.57 ± 11.57 kg) volunteered.

MAIN OUTCOME MEASURE(S)

Participants completed the Health Belief Model Scale and the Theory of Planned Behavior Scale (TPBS) on 1 occasion. The Health Belief Model Scale contains 9 subscales (perceived susceptibility, perceived consequences, fear of injury, perceived benefits, perceived barriers, community-led self-efficacy, individual self-efficacy, general health cues, external health cues), whereas the TPBS has 5 subscales (perceived benefits, perceived barriers, perceived social norms, social influence, intention to participate). The independent variables were race (White versus Black, Indigenous, and other people of color [BIPOC]) and National Collegiate Athletic Association division (I and III). Mann-Whitney U tests were used to detect differences in attitudes toward IPP participation based on race and collegiate division.

RESULTS

White female athletes perceived fewer TPBS barriers to participation in IPPs (P = .003) and more community-led self-efficacy when compared with BIPOC female athletes (P = .009). Division I athletes perceived a greater fear of injury (P = .002) and more general health cues (P = .01) than Division III athletes.

CONCLUSIONS

For lower extremity IPPs, BIPOC and Division III female collegiate athletes may need different implementation strategies. Individuals who identify as BIPOC may benefit from interventions focusing on solutions for common barriers to participation and improving community-led self-efficacy, and Division III athletes may benefit from interventions focusing on education related to the risk of injury and general preventive health behaviors.

Injury prevention for women and girls playing Australian Football: programme cocreation, dissemination and early adopter coach feedback

Background

Adherence to injury prevention programmes may improve with greater end-user involvement and application of implementation frameworks during development. We describe the cocreation, initial dissemination and feedback from programme early adopters (coaches), to develop the first evidence-informed injury prevention programme for women playing community Australian Football (Prep-to-Play).

Methods

We used a pragmatic seven-step process for developing sports injury prevention programmes to (1) gain organisational support, (2) compile research evidence, (3) consult experts, (4) engage end-users, (5) test programme acceptability, (6) evaluate against theory and (7) gain early adopter feedback. All Australian Football-registered coaches of women's/girls' teams were sent a postseason survey to determine initial awareness, adoption and implementation (steps 5 and 6). Purposively selected coaches were invited to interviews/focus groups (step 7) to identify competency, organisational and leadership implementation drivers with a deductive thematic analysis applied.

Results

Prep-to-Play was cocreated using previous efficacious programmes and expert input (steps 1-4), and disseminated via the national sporting organisation in preseason 2019 to all registered coaches (step 5). 343 coaches (90 women) completed the postseason survey and 22 coaches (5 women) participated in an interview (n=9) or focus group (n=13) (steps 6 and 7). 268 coaches (78%) were aware of Prep-to-Play. Of those aware, 218 (81%) had used (at least one element) Prep-to-Play, and 143 (53%) used it at least twice per week. Competency drivers included local expert-delivered face-to-face workshops complimented by online content and ongoing support. Organisational drivers included coach education integrated into existing league/club. Leadership drivers included compulsory injury prevention education integrated into coach reaccreditation processes or incentivisation via recognition (eg, professional development points).

Conclusions

Cocreation and organisational support resulted in high programme awareness and adoption. However, high fidelity implementation and maintenance may need to be facilitated by competency, organisational and leadership drivers. Responsibility should be shared among all stakeholders.

Youth Injury Knowledge and Beliefs following Neuromuscular Training Warm-up Implementation in Schools

Neuromuscular training warm-up programs can reduce injury rates in youth sports, but they often have poor uptake and adherence. Delivering such programs in school physical education classes may provide greater public health benefit, particularly if they promote improved injury knowledge and prevention beliefs amongst students. The purpose of this secondary analysis of a large cluster-randomized controlled trial was to understand how students' (age 11-15 years) knowledge and beliefs change after exposure to an evidence-informed neuromuscular training warm-up program. Six schools delivered the program for a 12-week period in the initial study year (n=566) and two continued to use it in a subsequent "maintenance" year (n=255). Students completed a knowledge and beliefs questionnaire at baseline, 6-week, and 12-week timepoints. Knowledge scores ranged from 7/10 to 8/10 at all timepoints and students generally believed that injuries are preventable. On average, there was less than a one-point change in knowledge between timepoints and there was no change in the median belief scores. There were no meaningful differences between sexes, grades, or previous injury. These findings highlight that knowledge and beliefs are unlikely to change passively through program exposure. More active strategies are needed to improve injury prevention perceptions in this population.

Effectiveness of an optional breastfeeding course for multidisciplinary undergraduate healthcare students: A quasi-experimental study

AIMS

This study aimed to examine and quantify the effectiveness of an optional breastfeeding course for multidisciplinary undergraduate healthcare students and to provide advice for education improvement based on students' characteristics and learning feedback.

BACKGROUND

Breastfeeding has received global awareness and educating undergraduate healthcare students is a prospective way to promote breastfeeding. This is the first report from mainland China to verify the education effects and formulate a proposal for improvement.

DESIGN

A quasi-experimental study with a one-group pretest-posttest design.

METHODS

An optional breastfeeding course covering eight topics based on the Health Belief Model was conducted for multidisciplinary students in a medical college. The Breastfeeding Knowledge Questionnaire, Iowa Infant Feeding Attitude Scale and Breastfeeding Promotion Intention Scale were completed for pre- and post-education comparison. The Wilcoxon signed-rank test, MannWhitney U test, KruskalWallis test and chi-square test were used for statistical analysis. The class average normalized gain and individual students' normalized gain were calculated to quantify the effectiveness from the perspective of learning gain.

RESULTS

From March to November 2021, 102 students specialized mainly in nursing, clinical medicine, medical imaging technology and midwifery took the course. Knowledge, attitudes and intention scores improved significantly (Z = 8.70, 8.72, 7.64, respectively, p < .001) and the class average normalized gains were 81.0%, 52.3% and 70.6%, respectively. Insignificant differences were found for students of different genders and categories of specialties (p > .05). Students of first year had significantly higher individual normalized gains (p < .05). In learning feedback, the top-ranked advice for course improvement was to increase practice and experience (75.5%).

CONCLUSIONS

This optional breastfeeding course produced medium to high learning gains for multidisciplinary healthcare undergraduates. Independent breastfeeding education based on behavioral theory for multidisciplinary students is recommended to be conducted in medical colleges. The addition of practice and experience may add value to such education.

Promoting behavior-related low back health in nurses by in-person and social media interventions in the workplace

BACKGROUND

Nurses are put at high risk of work-related low back pain due to the nature of their work. The aim of this study was to develop and evaluate intervention based on the PRECEDE-PROCEED Model on promoting behaviors of low back health via two educational approaches.

METHODS

This study was a community randomized-controlled clinical trial. The educational content was developed with six modules: knowledge, attitude, self-efficacy, reinforcing factors, enabling factors, and behavior. Intervention was delivered by two modes: (1) in-person (n = 60) and (2) social media (n = 60). Data were evaluated by a self-designed questionnaire at baseline, 3, and 6 months. Baseline comparisons between groups were made with Mann-Whitney U Test and T-Test. Comparison of change scores between groups and two delivery types across the three time periods used the mixed between-within subject analysis of variance.

RESULTS

A total of 120 nurses received the allocated intervention. All educational component scores increased at 3-months in both groups. At the 6-month follow-up scores increased for enabling factors and behavior in the intervention group, while in the control group all scores increased except for attitude. Based on Bonferroni Post hoc analysis social media was more effective in knowledge, self-efficacy, reinforcing factors, and behavior than the in-person intervention.

CONCLUSION

An educational program for low back health based on the PRECEDE-PROCEED model proved effective at improving all components. However, social media was more successful than in-person in the maintenance of behavior over the long term.

TRIAL REGISTRATION

IRCT20170313033054N2: 25-02-2018. https://www.irct.ir/trial/25598.

Evaluation of an injury prevention programme (Prep-to-Play) in women and girls playing Australian Football: design of a pragmatic, type III, hybrid implementation-effectiveness, stepped-wedge, cluster randomised controlled trial

INTRODUCTION

Due to the increase in participation and risk of anterior cruciate ligament (ACL) injuries and concussion in women's Australian Football, an injury prevention programme (Prep-to-Play) was codesigned with consumers (eg, coaches, players) and stakeholders (eg, the Australian Football League). The impact of supported and unsupported interventions on the use of Prep-to-Play (primary aim) and injury rates (secondary aim) will be evaluated in women and girls playing community Australian Football.

METHODS AND ANALYSIS

This stepped-wedge, cluster randomised controlled trial will include ≥140 teams from U16, U18 or senior women's competitions. All 10 geographically separated clusters (each containing ≥14 teams) will start in the control (unsupported) phase and be randomised to one of five dates (or 'wedges') during the 2021 or 2022 season to sequentially transition to the intervention (supported Prep-to-Play), until all teams receive the intervention. Prep-to-Play includes four elements: a neuromuscular training warm-up, contact-focussed football skills (eg, tackling), strength exercises and education (eg, technique cues). When transitioning to supported interventions, study physiotherapists will deliver a workshop to coaches and player leaders on how to use Prep-to-Play, attend team training at least two times and provide ongoing support. In the unsupported phase, team will continue usual routines and may freely access available Prep-to-Play resources online (eg, posters and videos about the four elements), but without additional face-to-face support. Outcomes will be evaluated throughout the 2021 and 2022 seasons (~14 weeks per season).

PRIMARY OUTCOME

use of Prep-to-Play will be reported via a team designate (weekly) and an independent observer (five visits over the two seasons) and defined as the team completing 75% of the programme, two-thirds (67%) of the time.

SECONDARY OUTCOMES

injuries will be reported by the team sports trainer and/or players. Injury definition: any injury occurring during a football match or training that results in: (1) being unable to return to the field of play for that match or (2) missing ≥ one match. Outcomes in the supported and unsupported phases will be compared using a generalised linear mixed model adjusting for clustering and time. Due to the type III hybrid implementation-effectiveness design, the study is powered to detect a improvement in use of Prep-to-Play and a reduction in ACL injuries.

ETHICS AND DISSEMINATION

La Trobe University Ethics Committee (HREC 20488) approved. Coaches provided informed consent to receive the supported intervention and players provided consent to be contacted if they sustained a head or knee injury. Results will be disseminated through partner organisations, peer-reviewed publications and scientific conferences.

TRIAL REGISTRATION NUMBER

NCT04856241.

Understanding Youth Sport Coaches' Perceptions of Evidence-Based Injury-Prevention Training Programs: A Systematic Literature Review

OBJECTIVE

To systematically review and summarize the knowledge, attitudes, beliefs, and contextual perceptions of youth sport coaches toward injury-prevention training programs by using the Theoretical Domains Framework to guide the organization of results.

DATA SOURCES

Systematic searches of PubMed and Google Scholar were undertaken in November 2021.

STUDY SELECTION

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol was followed. Results were limited to full-text articles that were published in peer-reviewed journals and printed in English. Additional studies were added after a citation search of included studies. Studies were eligible for inclusion if researchers evaluated youth sport coaches' knowledge, beliefs, contextual perceptions, or all 3 of anterior cruciate ligament injury-prevention training programs.

DATA EXTRACTION

Data charting was performed by 1 author and confirmed by a separate author.

DATA SYNTHESIS

Of the 1194 articles identified, 19 were included in the final sample. Among articles in which researchers assessed knowledge (n = 19), coaches' awareness of the existence and components of injury-prevention training programs was inconsistent. Among articles in which researchers assessed beliefs (n = 19), many coaches had positive attitudes toward injury-prevention training programs, but few believed youth athletes are at a high risk of injury. Among articles in which researchers assessed contextual perceptions (n = 13), many coaches did not feel they had access to information about injury-prevention training programs and cited a lack of time, space, support, and other resources as barriers to implementation.

CONCLUSIONS

Our findings support the need for programs, protocols, and policies to enhance knowledge of and support for youth sport coaches who wish to implement injury-prevention training programs. A gap exists in the research about addressing the needs of youth sport coaches in the United States high school sports setting. The use of multilevel implementation science frameworks (such as the Theoretical Domains Framework) will be beneficial for identifying constructs that affect implementation and developing train-the-trainer programming to meet the needs of individual youth sport coaches.

Educational intervention program based on health belief model and neck pain prevention behaviors in school teachers in Tehran

Background

Prevention of musculoskeletal disorders as one of the most common occupational health problems among the working population in both developed and developing countries is an important necessity and priority. The aim of this study was to evaluate the effectiveness of an educational intervention program based on the Health Belief Model (HBM) to increase awareness, perceived sensitivity, perceived severity, perceived benefits, and self-efficacy in adopting neck health-promoting behaviors in school teachers.

Methods

The present study was a quasi-experimental of the randomized clinical trial that was conducted for 6 months (December 2020 to July 2021). Participants were 146 junior high school teachers were selected from 26 schools through random sampling and divided into two groups of intervention and control. The data collection instrument was the self-design questionnaire and was completed in three points of time (before, immediately, and 3 months after the intervention). The data were analyzed by software version 24 SPSS.

Results

The results showed that awareness, perceived sensitivity, perceived severity, perceived benefits and barriers, and self-efficacy in adopting neck health-promoting behaviors in the intervention group increased in two points of time (immediately after the intervention and 3 months of follow-up) (P <  0.05).

Conclusion

Designing and implementing an educational intervention based on HBM could affect in adopting neck health-promoting behaviors among teachers.

Trial registration

IRCT20210301050542N1, 16/03/2021 first registration has been approved in Iranian Registry of Clinical Trials at (16/03/2021).

Cocreating injury prevention training for youth team handball: bridging theory and practice

Although it is advocated that end-users are engaged in developing evidence-based injury prevention training to enhance the implementation, this rarely happens. The ‘Implementing injury Prevention training ROutines in TEams and Clubs in youth Team handball (I-PROTECT)’ uses an ecological participatory design incorporating the perspectives of multiple stakeholders throughout the project. Within the I-PROTECT project, the current study aimed to describe the development of holistic injury prevention training specifically for youth handball players through using knowledge from both end-users (coaches and players) and researchers/handball experts. Employing action evaluation within participatory action research, the cyclical development process included three phases: research team preparation, handball expert-based preparation and end-user evaluation to develop injury prevention training incorporating both physical and psychological perspectives. To grow the knowledge of the interdisciplinary research team, rethinking was conducted within and between phases based on participants’ contributions. Researchers and end-users cocreated examples of handball-specific exercises, including injury prevention physical principles (movement technique for upper and lower extremities, respectively, and muscle strength) combined with psychological aspects (increase end-user motivation, task focus and body awareness) to integrate into warm-up and skills training within handball practice. A cyclical development process that engaged researchers/handball experts and end-users to cocreate evidence-based, theory-informed and context-specific injury prevention training specifically for youth handball players generated a first pilot version of exercises including physical principles combined with psychological aspects to be integrated within handball practice.

Contribution of a positive psychology-based conceptual framework in reducing physician burnout and improving well-being: a systematic review

BACKGROUND

The PERMA Model, as a positive psychology conceptual framework, has increased our understanding of the role of Positive emotion, Engagement, Relationships, Meaning, and Achievements in enhancing human potentials, performance and wellbeing. We aimed to assess the utility of PERMA as a multidimensional model of positive psychology in reducing physician burnout and improving their well-being.

METHODS

Eligible studies include peer-reviewed English language studies of randomized control trials and non-randomized design. Attending physicians, residents, and fellows of any specialty in the primary, secondary, or intensive care setting comprised the study population. Eligible studies also involved positive psychology interventions designed to enhance physician well-being or reduce physician burnout. Using free text and the medical subject headings we searched CINAHL, Ovid PsychINFO, MEDLINE, and Google Scholar (GS) electronic bibliographic databases from 2000 until March 2020. We use keywords for a combination of three general or block of terms (Health Personnel OR Health Professionals OR Physician OR Internship and Residency OR Medical Staff Or Fellow) AND (Burnout) AND (Positive Psychology OR PERMA OR Wellbeing Intervention OR Well-being Model OR Wellbeing Theory).

RESULTS

Our search retrieved 1886 results (1804 through CINAHL, Ovid PsychINFO, MEDLINE, and 82 through GS) before duplicates were removed and 1723 after duplicates were removed. The final review included 21 studies. Studies represented eight countries, with the majority conducted in Spain (n = 3), followed by the US (n = 8), and Australia (n = 3). Except for one study that used a bio-psychosocial approach to guide the intervention, none of the other interventions in this review were based on a conceptual model, including PERMA. However, retrospectively, ten studies used strategies that resonate with the PERMA components.

CONCLUSION

Consideration of the utility of PERMA as a multidimensional model of positive psychology to guide interventions to reduce burnout and enhance well-being among physicians is missing in the literature. Nevertheless, the majority of the studies reported some level of positive outcome regarding reducing burnout or improving well-being by using a physician or a system-directed intervention. Albeit, we found more favorable outcomes in the system-directed intervention. Future studies are needed to evaluate if PERMA as a framework can be used to guide system-directed interventions in reducing physician burnout and improving their well-being.

RunIn3: the development process of a running-related injury prevention programme

BACKGROUND

Running is an important type of exercise to keep people physically active. However, running also carries a risk of developing running-related injuries (RRI). Therefore, effective and evidence-based RRI prevention programmes are desirable, but are scarce in practice. An approach to face this problem might be the application of methods to develop RRI prevention programmes based on theories of behaviour change.

OBJECTIVE

The purpose of the study was to develop an RRI prevention programme based on perspectives of behavioural and social science theories, as well as taking a framework development approach.

METHODS

This was a qualitative study using the Intervention Mapping (IM) framework held between February and March 2018 in São Paulo, Brazil. The participants were involved in running practice. The data collection was conducted during focus group meetings. The data analysis was based on semantic thematic approach using a content analysis orientation based on inductive reasoning.

RESULTS

The target population of the RRI prevention programme identified was 'adult recreational runners'. The objectives of the RRI prevention programme were established in two broad actions: (1) to provide feedback on individual training characteristics and RRI risk; and (2) provide/enhance knowledge, skills and self-efficacy on RRI preventive behaviours. The programme is aimed to be delivered through an online system.

CONCLUSION

An RRI prevention programme was developed using the IM framework and a participatory approach. The programme was named 'RunIn3', and it is based on providing feedback on running volume and RRI risk, as well as providing knowledge, skills and self-efficacy on RRI preventive behaviours.

Canadian High School Rugby Coaches Readiness for an Injury Prevention Strategy Implementation: Evaluating a Train-the-Coach Workshop

Background: Canadian rugby coach injury prevention beliefs and attitudes have not been studied, yet are key to informing injury prevention strategy implementation. Despite neuromuscular training (NMT) warm-up success in reducing injury, adoption of these programs is variable. Therefore, objectives of this study included (1) describing Canadian youth rugby coach injury prevention beliefs and attitudes and current warm-up practices and (2) evaluating intention to use a rugby-specific NMT warm-up.

Methods: High school rugby coaches completed a questionnaire before and after a rugby-specific NMT warm-up workshop. The pre-workshop questionnaire captured demographics, current warm-up practice, and NMT warm-up knowledge and use. Both questionnaires captured injury prevention beliefs, attitudes and behavioral intention.

Results: Forty-eight coaches participated in the workshops. Pre-workshop, 27% of coaches were aware of NMT warm-ups. Coaches primarily included aerobic and stretching components, while balance components were not common in their warm-ups over the past year. Additionally, 92% of coaches agreed to some extent they would “complete a rugby-specific warm-up program prior to every game and training session this season.” Post-workshop, 86% of coaches agreed to some extent that they would use the program in every rugby session. No differences were observed between pre- and post-workshop intention to implement the warm-up (p = 0.10).

Interpretation: This is the first study to examine current Canadian youth rugby coach warm-up practices and intention to use NMT warm-ups. Canadian rugby coach intention to use a rugby-specific NMT warm-up is high, providing ample opportunity to investigate the efficacy of a NMT warm-up in youth rugby.

Can we explain running-related injury preventive behavior? A path analysis

BACKGROUND

Behavioral and social science theories/models have been gaining attention in sports injury prevention.

OBJECTIVE

To investigate the potential of the Theory of Planned Behavior in explaining running-related injury preventive behavior.

METHODS

Six-month prospective cohort study based on data gathered from a randomized controlled trial. From a total of 1512 invited trail runners, 232 were included in this study. Preventive behaviors and their determinants were assessed at baseline and two and six months after baseline. Five-point Likert scales were used to assess the determinants of preventive behavior. A Bayesian path analysis was conducted applying mixed models and mediation analysis.

RESULTS

A 1-point increase in intention, attitude, subjective norm, and perceived behavioral control predicted an increase of 54% (95% Bayesian credible interval [BCI]: 38, 71) in the rate of performing running-related injury preventive behavior, explaining 49% (R² 0.49; 95% BCI: 0.41, 0.56) of the variance around preventive behavior. Intention and perceived behavioral control predicted running-related injury preventive behavior directly, while 40% (95% BCI: 21, 61) and 44% (95% BCI: 20, 69) of the total effect of attitude was mediated by intention and perceived behavioral control, respectively. Attitude, subjective norm, and perceived behavioral control predicted intention.

CONCLUSIONS

The Theory of Planned Behavior may have the potential to explain half of the variance around running-related injury preventive behavior and intention. Therefore, such theory may be considered a relevant and useful tool in developing, investigating, and/or implementing programs aimed at preventing running-related injuries.

Predicting psychological factors affecting regular physical activity in hypertensive patients: Application of health action process approach model

Aim

The aim of this study was to determine the factors affecting the behaviour of regular physical activity in patients with hypertension using the health action process approach (HAPA) model.

Design

This cross-sectional study was conducted on 176 hypertension patients, in Astaneh-e-Ashrafiyeh, Guilan, Iran, 2018-2019.

Methods

Data collection tools included demographic characteristics, medical history, the short form of International Physical Activity Questionnaire (IPAQ) and scales related to the HAPA model. The data were analysed using chi-square, independent t test, one-way ANOVA, Pearson's correlation coefficient and path analysis on AMOS, version 23.0.

Results

Action self-efficacy (β = 0.59), outcome expectancy (β = 0.20) and risk perception (β = 0.18) had a statistically significant effect on intention. Moreover, the path coefficient between intention (β = 0.35) and coping self-efficacy (β = 0.29) with physical activity was statistically significant. The results revealed that HAPA constructs were able to describe 45% of the variance in intention and 31% of the variance in physical activity behaviour.

Conclusion

The HAPA model is a useful framework for describing the factors affecting physical activity in hypertension patients.

An intervention based on the health belief model led to improvements in self-efficacy towards ERIPP participation and functional performance in club sport athletes: a pilot study

OBJECTIVES

To determine if an intervention based on the Health Belief Model (HBM) could improve attitudes towards exercise-related injury prevention program (ERIPP) participation and functional performance in club sport participants.

DESIGN

Repeated measures METHODS: Participants completed the HBM Scale (HBMS) and Theory of Planned Behavior Scale (TPBS) to assess attitudes towards ERIPP participation at three time points (pre-measure, post-measure, follow-up measure). The HBM based intervention was delivered immediately following the pre-measure containing: 1) education on ERIPPs, benefits and barriers to participating, strategies to overcome barriers, risk factors and consequences for lower extremity injuries, and strategies to prevent lower extremity injuries 2) individualized feedback on functional performance 3) demonstration and participation in the 11+. Attitudes towards injury prevention were compared using the subscales of the HBMS and TPBS at all three time points. Functional performance was compared at the pre-measure and follow-up measure.

RESULTS

Significant improvements with large effect sizes were detected in individual self-efficacy from pre-test (0.73±4.48) to post-test (2.93±4.30; P=0.05; ƞ2=0.18) and pre-test to follow-up (3.20±3.49; P=0.04; ƞ2=0.20) and community led self-efficacy from pre-test (4.40±2.75) to post-test (6.07±3.43; P=0.02; ƞ2=0.24) and pre-test to follow-up (7.07±2.05; P=0.001; ƞ2=0.44). Additionally, significant improvements were found in the LESS-RT following the intervention.

CONCLUSIONS

The intervention based on the HBM led to improvements in individual and community led self-efficacy indicating an enhancement in the participants' confidence in their ability to participate in an ERIPP. Future research should investigate the effectiveness of individualized interventions to improve attitudes towards and adherence to ERIPPs.