p-ISSN: 1300-0551
e-ISSN: 2587-1498

Sabriye Ercan1, Özgür Önal2

1Sports Medicine Department, Faculty of Medicine, Süleyman Demirel University, Isparta, Turkey
2Public Health Department, Faculty of Medicine, Süleyman Demirel University, Isparta, Turkey

Keywords: injuries, prevention, knowledge, awareness

Abstract

Objective: This study aimed to develop the Sports Injury Prevention Awareness Scale (SIPAS) and to determine its validity and reliability for use with the Turkish population.

Materials and Methods: This methodological study was initiated after approval by the local ethics committee. After a review of the literature, a pool of 31 items was developed. The items were organized into a 5-point Likert-type scale (Scale v.1), and the content validity of this pilot-scale was assessed using the Lawshe method, for which expert opinion was used to determine content validity ratio (CVR) and content validity index (CVI). Subsequently, the pilot-scale was applied to a sample of at least 10 times the number of items. Participants' descriptive information, and responses were recorded electronically (Google Forms). Data were analyzed and the validity and reliability of the scale were assessed using SPSS v.23 and AMOS v.24.

Results: The content validity of the scale (Scale v.1) was assessed using opinions from 18 experts. Items that did not meet the minimum CVR threshold were eliminated (k=2). The remaining 29-item scale (Scale v.2) had a CVI of 0.696 and was applied to a total of 379 participants (147 males, 38.8%; 232 females, 61.2%) with a mean age of 29.2±11.3 years. From Scale v.2, a total of 11 items were removed due to reducing Cronbach's alpha coefficient (k=5), lack of variables (k=1), or cross-loading between factors (k=5). The remaining 18 items (Scale v.3) explained 59.7% of the variance. Analyses revealed four factors with eigenvalues λ>1.0. The reliability of Scale v.3 was demonstrated with a Spearman-Brown reliability coefficient of 0.778, a Guttman split-half reliability coefficient of 0.772, and a Cronbach's alpha reliability coefficient of 0.884. Scale v.3 satisfied the goodness-of-fit indices in confirmatory factor analysis.

Conclusions: The 18-item four-factor (health status, environmental factors and equipment, exercise session, exercise program) Sports Injury Prevention Awareness Scale is valid and reliable for use with Turkish individuals aged 13-66 years.

Introduction

Physical activity and exercise have well-established health benefits and are recommended by the World Health Organization for individuals of all ages (1-3). Physical activity of any frequency and type contributes to the cardiorespiratory system, cardiometabolic system (blood pressure, dyslipidemia, glucose, insulin, etc.), motor control, physical fitness, bone health, adiposity, diabetes, cancer prevention, mental health, cognitive functions, social behavior, and sleep (1,3,4). On the other hand, physical activity participation may have certain adverse effects (4,5), including musculoskeletal injuries, as well as dehydration and heatstroke (6).

Data from epidemiological studies indicate that 60% of all injuries treated in Scandinavian medical facilities were sports-related. Moreover, 30% of all pediatric sports injuries require medical care (4). In the United States, 11% of emergency admissions were due to sport and active recreation-related injuries (4). On the other hand, more and more studies investigate approaches for sports injury prevention, and offer suggestions for reducing sports injuries (4,7-10) since physical activity participation is associated with substantial personal and social benefits (1,11,12).

The frequency and severity of sports injuries can be reduced provided that necessary measures are taken (5,13,14). The numerous proposed theories and models prominently recommend developing knowledge and awareness in the society (15-17). Given the contribution of physical activity to well-being (1-3), efforts should focus on encouraging participation in physical activity and increasing awareness regarding adoption of sports injury prevention methods.

There is a need for tools that can be used for the measurement and assessment of sports injury prevention awareness. This study aimed to develop the Sports Injury Prevention Awareness Scale and to determine its validity and reliability for use with the Turkish population.

Material and Methods

This methodological study was initiated after approval by the local ethics committee. Informed consent was obtained from all participants. We constructed our scale following the steps described in the literature, including literature review, creating an item pool, expert review, and pilot testing (18).

Review of the literature did not reveal a sports injury prevention awareness measurement tool. Subsequently, a pool of 31 items that would be understandable by Turkish individuals was created. The items were organized into a 5-point Likert-type scale (Scale v.1), and the content validity of this pilot-scale was assessed using the Lawshe method (19).Accordingly, expert opinion was obtained between October and November 2020 to determine the fitness of each item to measure the relevant domain. Quantitative data from experts were analyzed, and content validity ratio (CVR) and the content validity index (CVI) were calculated (19). After achieving content validity, Scale v.2 was developed for a pilot application.

The pilot study was applied to a sample of at least 10 times the number of items (20). The study included people living in Turkey aged >12 years who were literate in Turkish, and who could give reliable answers to the survey. Participants' descriptive information, and responses were recorded electronically (Google Forms).

Statistical Analysis

Data were analyzed using SPSS v.23 and AMOS v.24. Participants' descriptive characteristics were analyzed using frequencies, percentages, and means. For validity and reliability studies, the suitability of the sample for analysis was evaluated with the Kaiser-Meyer-Olkin (KMO) measure of sample adequacy and Bartlett's test of sphericity. The scale was then assessed with item analysis, item-to-total correlation, Cronbach's α, split-half method, and exploratory and confirmatory factor analysis.

Results

Content validity

Content validity was assessed using the opinions of 18 experts (five Sports Medicine, three Orthopedics and Traumatology, three Physiotherapy and Rehabilitation, two Public Health, two Sports Science, one Family Medicine, one Pediatrics, one Biostatistics), all of whom held at least the rank of assistant professor. A language expert examined the grammar of the scale items. According to the number of experts, the CVR threshold was determined as 0.444. From the 31-item Scale v.1, two items that did not meet the minimum CVR threshold were removed, and three items were revised. The subsequent 29-item Scale v.2 had a CVI of 0.696 and was content-valid (19).

Pilot study and participants' descriptive characteristics

Scale v.2 was applied to a total of 379 participants (147 males, 38.8%; 232 females, 61.2%) with a mean age of 29.2±11.3 years. The mean body-mass index was 24.1±4.5 kg/m2. Among the participants, 7.1% (n=27) had completed primary education and 18.7% (n=71) secondary education, 64.4% (n=244) had received post-secondary education, and 9.8% (n=37) had a master's degree or doctorate. About 13.5% (n=51) of the participants reported having a known chronic disease, 76.5% (n=39) of which regularly used medication for their condition. Nearly 52.5% (n=199) of the participants reported having participated in physical activity at some point in their lives and 18.2% (n=69) had a history of sports injury.

Reliability and construct validity

From Scale v.2, five items were removed due to reducing Cronbach's alpha coefficient and one due to lack of variables. Item score averages were similar. There were no items with a standard deviation of zero or an item-to-total correlation coefficient below 0.25 (19). All items had positive discrimination indices (19), and were statistically significant in the independent samples t-test (p<0.001). Scale results were not affected by a ceiling (1.6%) or floor effect (0.3%).

The KMO measure of sampling adequacy was 0.884, and Bartlett's test of sphericity was highly significant (χ2=2789,709, p<0.001). Anti-image correlation results were >0.50 for all items. Construct validity was assessed by the principal components method of exploratory factor analysis. The scree plot revealed a four-factor model with eigenvalues (λ) of ≥1.00 (Figure 1). For factor rotation, the oblimin rotation method, an oblique rotation technique was performed. Five items were removed from the scale due to cross-loading between factors.

The remaining 18 items (Scale v.3) explained 59.7% of the variance. Analyses revealed four factors with eigenvalues λ>1.0: health status (λ=6.52, explained 36.2% of the variance), environmental factors and equipment (λ=1.82, explained 10.1% of the variance), exercise session (λ=1.28, explained 7.1% of the variance), and exercise program (λ 1.12, explained 6.2% of the variance). For each item, the average score, item-to-total correlation, discrimination indices, factor loadings, and rotated factor loadings are presented in Table 1.

The reliability of Scale v.3 was demonstrated with a Spearman-Brown reliability coefficient of 0.778, a Guttman split-half reliability coefficient of 0.772, and a Cronbach's alpha reliability coefficient of 0.884. The reliability of all four factors of the scale was calculated and presented in Table 2.

Based on a favorable exploratory factor analysis, confirmatory factor analysis was performed, and the model’s goodness-of-fit was assessed (21), which indicated a good model-data fit. Goodness-of-fit results from confirmatory factor analysis are presented in Table 3 and the path diagram is presented in Figure 2.

Discussion

In this study, we developed the 18-item Sports Injury Prevention Awareness Scale (SIPAS) (Appendix 1). The scale is found to be valid and reliable to assess sports injury prevention awareness in Turkish individuals aged 13-66 years under four domains: health status (items 1-4), environmental factors and equipment (items 5-9), exercise session (items 10-14), and exercise program (items 15-18). The scale does not contain any reverse-scored items, and the total score is calculated by summing the ratings of each item. A higher score indicates better sports injury prevention knowledge and awareness.

Review of the literature did not reveal a tool for the measurement of sports injury prevention knowledge and awareness. Accordingly, we aimed to develop a scale based on the knowledge available in the current literature. We first created an item pool (18) and subsequently assessed content validity using expert opinion.

The Lawshe method, which involves referring to expert opinion, is commonly used to confirm content validity. This method involves analyzing quantitative data from experts to calculate content validity ratio (CVR) and content validity index (CVI) in order to develop a pilot-scale (19). According to the number of experts consulted for our pilot-scale; it was observed that the pilot scale form provided the smallest CVR of 0.42 and CVI value suggested to be greater than 0.67 (19). Therefore, SIPAS was determined to be content-valid.

After confirming content validity, the literature recommends the pilot-scale to be applied to a sample of at least 10 times the number of items (20). We accordingly aimed to include at least 10 times the number of items in SIPAS. Since SIPAS is based on the summation of individual items' scores, the reliability of the scale was examined by item analysis (19). The average scores of the items were similar and there were no items with a standard deviation of zero. Moreover, there were no items with an item-to-total correlation coefficient below 0.25. If removing a specific item from the scale results in increased overall reliability, that item is called an "unreliable item" and should be eliminated (19). In the present study, five items were removed from Scale v.2 due to decreasing the Cronbach's alpha coefficient. Further analyses indicated that the final version (Scale v.3) did not contain any "unreliable" items.

High discrimination power requires a statistically significant (p˂0.05) difference between the mean scores of participants who got the item right and those who got the item wrong, and a non-negative t-value (19). All items of SIPAS met these criteria. The literature indicates that the proportion of participants that scored maximum or minimum should not exceed 5-20%. If a higher proportion of subjects scored maximum or minimum, this results in a ceiling or a floor effect, in other words, it is not possible to discriminate between the top or bottom end of the scale (19). For SIPAS, 1.6% of the participants scored the maximum possible score and 0.3% scored the minimum possible score, indicating no ceiling or floor effect.

Construct validity was assessed by factor analysis (19). The KMO measure of sampling adequacy was 0.884 for SIPAS, indicating very good sampling adequacy (20). Bartlett's test of sphericity is used to determine whether the correlation matrix is an identity matrix and whether the data are statistically significant with the value of the test statistic. For SIPAS, Bartlett's test of sphericity was significant (p<0.05) (19,20). Items with anti-image correlation matrices below 0.05 must be removed from a given scale (19). All items of SIPAS had anti-image correlation results >0.50. Therefore, the scale was suitable for factor analysis.

There are several different factor extraction methods for factor analysis, and the most used one is the principal components method. This method focuses on factors that will explain the highest variance in all variables (20). To be included in the model, each factor must have an eigenvalue greater than 1.0 and account for at least 5% of the total variance (19,20). The number of components to be retained in the model can also be determined with a scree plot (18,19). A model that can explain 50-70% of total variance is accepted as adequate (19). In reference to the literature and our analyses, we determined that our scale adequately measured sports injury prevention awareness under four domains.

Unrotated factor loadings obtained with the principal components method may be insufficient for factor analysis, which can be overcome by factor rotation. Oblique rotation methods (such as direct oblimin or promax) are often preferred when the factor correlation coefficient is ≥0.32 (19). In reference to the literature, we performed the oblimin rotation method for factor rotation. After factor rotation, all rotated factor loadings of the model were above 0.40. However, fiveitems were removed from the scale due to cross-loading between factors.

Reliability and construct validity analyses were repeated for the final version of SIPAS (Scale v.3) using Cronbach's alpha reliability coefficient, Spearman-Brown reliability formula, and Guttman split-half reliability formula (19). The final 18-item version of SIPAS was determined to be reliable.

Confirmatory factor analysis, a type of factor analysis, is being increasingly used in research. This method allows testing internal consistency and helps to reveal accuracy and causality and determines whether items belong to the same domain or factor. The goodness and fitness of the proposed model are determined with fitness indices in confirmatory factor analysis (18). SIPAS met all recommended goodness-of-fit criteria (21), thus confirming the study hypothesis.

As to limitations, the study excluded individuals aged below 12 years, individuals illiterate in Turkish, and individuals who did not have the capacity to communicate sufficiently to give reliable answers to the scale.

To conclude, SIPAS is an 18-item four-factor (health status, environmental factors and equipment, exercise session, exercise program) scale that is valid and reliable for use with Turkish individuals aged 13-66 years. SIPAS can be used in scientific studies to measure sports injury prevention knowledge and awareness, and to measure objective progress after education programs.

Cite this article as: Ercan S, Onal O. Development, validity and reliability of the Sports Injury Prevention Awareness Scale. Turk J Sports Med. 2021;56(3):138-45; http://dx.doi.org/10.47447/tjsm.0546

Conflict of Interest

The authors declared no conflicts of interest with respect to authorship and/or publication of the article.

Financial Disclosure

The authors received no financial support for the research and/or publication of this article.

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