Award Date

May 2023

Degree Type


Degree Name

Doctor of Philosophy (PhD)


Interdisciplinary Programs

First Committee Member

Kara Radzak

Second Committee Member

Brian K. Schilling

Third Committee Member

Daniel Young

Fourth Committee Member

Jennifer Pharr

Number of Pages



INTRODUCTION: Among service members, musculoskeletal injuries threaten military readiness and place a substantial burden on medical and financial resources. While musculoskeletal injuries (MSKIs) are a leading threat to military readiness, service members’ unwillingness to seek care constrains current prevention and surveillance efforts. A growing body of evidence shows US service members conceal a large proportion of injuries, especially in training environments. The Reserve Officers’ Training Corps is a critical training environment for future US military commissioned officers. Reserve Officers’ Training Corps (ROTC) is the largest commissioning source of new officers for the US military. ROTC cadets are college students concurrently fulfilling officer training. They complete military courses and participate in physical and tactical training under the direction of military Service Members assigned to ROTC programs to serve as faculty and staff at US colleges. ROTC cadets report overuse musculoskeletal injuries (MSKIs) attributable to physical training (45.3% of all MSKIs), which is in line with MSKI incidence in other training environments. The overall purpose of the current study was to investigate injury concealment in ROTC cadets and identify potentially modifiable factors associated with concealment behaviors. The goal of Study 1 was to determine the prevalence of MSKI concealment in ROTC cadets and injury characteristics associated with concealment. The goal of Study 2 was to qualitatively explore perceptions, beliefs, and attitudes of ROTC cadets that influence MSKI reporting and concealment behaviors. Study 3 investigated if a brief, online educational video could increase ROTC cadets’ reporting intentions. The video covered the impact of MSKIs on military readiness and the importance of early help-seeking behavior to improve MSKI outcomes. In addition, we investigated if the message’s source (i.e., an ROTC peer or an ROTC authority figure) affected reporting intentions. METHODS: Study 1 invited Army, Air Force, and Naval cadets from six host universities participating in officer training to complete an online, self-reported survey regarding injury reporting and concealment. Cadets answered questions about pain or injuries experienced during officer training. Survey questions pertained to an injury’s anatomic location, onset, severity, functional limitations, and whether or not the injury had been reported. Cadets also selected factors that influenced the decision to report or conceal injuries from predetermined lists in a “choose any” fashion. A series of χ2 tests of independence compared the relationship between injury reporting and other injury characteristics for each individual injury. Study 2 used Consensual Qualitative Research methodology. US Army, Air Force, and Naval ROTC cadets participated in semi-structured interviews comprising 10 open-ended questions. Two researchers separately analyzed and inductively coded interview transcripts. Then, they combined the two analyses into a unified codebook which was used to recode transcripts deductively. The two coders and an auditor developed a final, consensus-based analysis, from which they identified emergent domains. Study 3 used a repeated measures design to evaluate the impact of two MSKI educational interventions, one delivered by a high-achieving Army ROTC cadet (peer-led) and the other delivered by an Army ROTC battalion commander (authority-led), on MSKI reporting intentions, as compared to each other and a non-MSKI related control intervention. The MSKI educational intervention video was based upon a 2018 study conducted by the Army showing that motivational speakers had a small, statistically significant effect toward reducing stigma of help-seeking for mental health. In the current study, other than their personal introductions and backgrounds, both individuals had the same script addressing four areas: (1) MSKI prevalence in ROTC, (2) the evidence of improved outcomes of early treatment on MSKI, (3) encouraging cadets to report their injuries and (4) addressing specific barriers and stigma beliefs previously identified in ROTC cadets. The control condition consisted of a video demonstrating appropriate exercise technique with voiceover movement critiques. An 8-item scale was developed to measure stigma regarding MSKI reporting and intentions to seek help for MSKI. Questions used 7-point Likert-scored response options, and the total survey score could range from 8 (most likely to seek help) to 56 (least likely to seek help). ROTC cadets were invited to participate via an anonymous survey link distributed by ROTC military instructors at 23 universities, were ROTC programs ranged in size from 30-150 cadets. Cadets who consented to participate were asked to complete the following using the online survey platform: 1) pre-intervention MSKI intentions scale, 2) watch a randomly assigned ~2:30-3:00 minute educational video (peer-led, authority-led, or control), and 3) repeat the MSKI intentions scale post-intervention. Analysis included responses from surveys completed in full. A two-way, mixed repeated measures ANOVA was performed in SPSS v.28 to assess group*time interaction effects and main effects for group and time based on mean scores pre- and post-intervention. For this analysis, a priori estimates with α=.05, 1-β=.8, and a small effect (Cohen’s f=.15) suggested a sample size of 111 participants was needed. RESULTS: One hundred fifty-nine cadets (121 Army, 26 Air Force, 12 Naval) completed the survey for Study 1. Eighty-five cadets disclosed a total of 219 injuries. Two-thirds of injuries (144/219) were concealed. Twenty-six percent of participants (22/85) reported all injuries, while the remainder (63/85, 74%) had at least one concealed injury. In relation to injury reporting/concealment, there was a weak association with injury onset (χ21=4.24, p=.04, V=.14), a moderate association with anatomic location (χ212=22.64, p=.03, V=.32), and relatively strong associations with injury severity (χ23=37.79, p<.001, V=.42) and functional limitations (χ23=42.91, p<.001, V=.44). Eleven ROTC cadets (6 Army, 3 Air Force, and 2 Naval) completed interviews for Study 2. Four major domains emerged from participants’ response data: perceptions of MSKIs in the military and ROTC, reasons for reporting injuries, reasons for concealing injuries, and proposed methods to improve reporting behaviors in cadets. ROTC cadets perceived injury reporting and the state of being injured as stigmatized, despite their awareness of MSKI prevalence. Cadets described only reporting injuries when severity hindered physical performance or made the injury difficult to conceal. Access to, and knowledge of, available health care influenced both reporting and concealment. Primarily, fear of social and career repercussions, along with a lack of healthcare access, drove cadets to conceal injuries. To improve reporting, ROTC cadets desired changes to the ROTC’s organizational culture and operational standards and procedures. Culturally, cadets desired increased acceptance and support for injured cadets and decreased minimization of the MSKI threat. Suggested operational changes to the ROTC included integrated health care, local injury surveillance and reporting systems, optimized physical training, and adding an injury-related curriculum. Study 3 included 100 ROTC cadets (61 male, 39 female) completed the study. Participants were primarily from Army ROTC programs (72 Army, 14 Air Force, 14 Naval). Pre-intervention mean scores: authority-led (n=31) = 20.3±9.4, peer-led (n=32) = 21.8±8.7, control (n=37) = 19.1±10.1, total=20.3±9.4. Post-intervention mean scores: authority-led=20.9±11.2, peer-led=20.2±10, control=17.3±7.7, total=19.7±9.3. There were no outliers, as assessed by examination of studentized residuals. There was homogeneity of variance and covariances based on Levene’s test and Box’s test, respectively. The assumption of sphericity was met for the two-way interaction based on Mauchly’s test. There was no significant group*time interaction (F(2,97)=.917, p=.403, η2partial=.019). There were no significant main effects for time (F(1,97)=1.461, p=.23, η2partial =.015) or group (F(2,97)=1.084, p=.342, η2partial =.022). CONCLUSIONS: Study 1 identified that 2/3 of injuries go unreported inf Reserve Officers’ Training Corps cadets. Functional limitations, symptom severity, and injury onset may be the largest factors that influence the decision to report or conceal musculoskeletal injuries. Study 2 suggests that ROTC cadets perceive military culture as one which trivializes the threat of MSKIs and stigmatizes those who are injured. Thereby, cadets’ fears of social and career repercussions become barriers to injury reporting. Findings from Study 3 indicate that a single educational intervention video does not influence MSKI help-seeking intentions of ROTC cadets. A potential limitation was the use of a video intervention. However, ROTC cadets previously identified electronic delivery as the desired mode to receive MSKI information, and a peer-education video intervention has been found to increase Veterans’ mental healthcare utilization (with a non-significant effect on help-seeking intentions). In contrast to the present study, the Veterans’ study used a website hosting 77 videos of Veterans with PTSD giving testimonials of personal help-seeking experiences, blending education and persuasion with peer support. It is possible sharing personal experiences could have more influence on help-seeking intentions than scripted encouragement. Current findings may indicate MSKI help-seeking intentions were already ingrained in this sample to the point a single intervention alone could not influence change. Previous research on concussion reporting indicates that concealment cultures may be systematic, and previous experiences leading to indoctrination of concealment can influence one’s reporting intentions. The current sample of cadets had already participated in ROTC for two years, on average. Future research should evaluate if MSKI help-seeking intentions change over the course of ROTC participation, or even over a military career. Addressing cadets’ injury concealment could improve service members’ health and military readiness and increase injury surveillance accuracy. To mitigate concealment, behavioral antecedents of reporting, such as perceptions and beliefs, must be identified and targeted for intervention. This work establishes the foundation for researching injury reporting in cadets and adds to existing military evidence on the topic.


Defense and Security Studies | Kinesiology | Medicine and Health Sciences

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Degree Grantor

University of Nevada, Las Vegas




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