Applying the Socio-Ecological Model to barriers to implementation of ACL injury prevention programs: A systematic review

Background: Preventing anterior cruciate ligament (ACL) injuries is important to avoid long-term adverse health consequences. Identifying barriers to implementation of these prevention programs is crucial to reducing the incidence of these injuries. Our purpose was to identify barriers of implementation for ACL injury prevention programs and suggest mechanisms for reducing the barriers through application of a Socio-Ecological Model (SEM). Methods: Studies investigating ACL prevention program effectiveness were searched in Medline via PubMed and the Cochrane Library, and a subsequent review of the references of the identified articles, yielded 15 articles total. Inclusion criteria encompassed prospective controlled trials, published in English, with ACL injuries as the primary outcome. Studies were independently appraised by 2 reviewers for methodological quality using the PEDro scale. Barriers to implementation were identified when reported in at least 2 separate studies. A SEM was used to suggest ways to reduce the identified barriers. Results: Five barriers were identified: motivation, time requirements, skill requirements for program facilitators, compliance, and cost. The SEM suggested ways to minimize the barriers at all levels of the model from the individual through policy levels. Conclusion: Identification of barriers to program implementation and suggesting how to reduce them through the SEM is a critical first step toward enabling ACL prevention programs to be more effective and ultimately reducing the incidence of these injuries. Keywords: Anterior cruciate ligament injury prevention, Barriers to implementation, Neuromuscular training programs, Socio-Ecological Model, Sports injury preventio