THE AVAILABILITY OF CERTIFIED ATHLETIC TRAINERS IN HIGH SCHOOLS IN MASSACHUSETTS A THESIS Submitted to the Faculty of the School of Graduate Studies and Research of California University of Pennsylvania in partial fulfillment of the requirements for the degree of Master of Science by Kathryn Annunziata Research Advisor, Dr. Carol Biddington California, Pennsylvania 2011 ii iii ACKNOWLEDGEMENTS First and foremost, I would like to thank my wonderful parents. Thank you for always being there for me and supporting me in whatever I am doing. To Tricia, Andrew and Kristen for being the most amazing older siblings anyone could ever have and for always helping me through anything. To Jojo, thank you for always encouraging me and being there to talk when I needed it. I love you all so much! To Robbie, you were always there to listen to my problems and help me relax during all those stressful nights working on my thesis. You’ve helped me through this past year more than you’ll ever know and I’m so grateful for you. I love you! Thank you to my girls Joanna, Jackie, and Kristin. We all became so close in such a short amount of time and made some great memories this year. I’m definitely going to miss living together and complaining about getting our research done! You guys are the best. I would like to give a huge thanks to my thesis advisor, Dr. Carol Biddington. Thank you for all your dedication to my research and for always pushing me in the right direction. I’m so grateful for all of your help. Also, thank you to my committee members, Dr. Karen Hjerpe and Dr. Joni Roh for all their much needed assistance and hard work. I have to thank Ms. Martha Jamieson, MSSADA President and Mr. Chris Aufiero, MSSADA Secretary for their help in distributing my survey to all the high school Athletic Directors in Massachusetts. Also, thank you to every Massachusetts high school Athletic Director that was able to take part in my survey. This study could not have been completed without your help. iv TABLE OF CONTENTS Page SIGNATURE PAGE . . . . . . . . . . . . . . . . ii AKNOWLEDGEMENTS . . . . . . . . . . . . . . . . iii TABLE OF CONTENTS LIST OF TABLES . . . . . . . . . . . . . . . . vii LIST OF FIGURES . INTRODUCTION METHODS . . . . . . . . . . . . . . . iv . . . . . . . . . . . . . . . viii . . . . . . . . . . . . . . . . . 1 . . . . . . . . . . . . . . . . . . . 6 Research Design. . . . . . . . . . . . . . . . 6 Subjects . . . . . . . . . . . . . . . . . Preliminary Research . 7 . . . . . . . . . . . . . 7 Instruments . . . . . . . . . . . . . . . . . 7 Procedures . . . . . . . . . . . . . . . . . 8 Hypotheses . . . . . . . . . . . . . . . . . 9 Data Analysis RESULTS . . . . . . . . . . . . . . . . 10 . . . . . . . . . . . . . . . . . . . 11 Demographic Data . . . . . . . . . . . . . . . 11 Hypotheses Testing . . . . . . . . . . . . . . 21 Additional Findings . . . . . . . . . . . . . . 25 DISCUSSION . . . . . . . . . . . . . . . . . . 30 Discussion of Findings . . . . . . . . . . . . . 30 Conclusions . . . . . . . . . . . . . . . . . 35 v Recommendations. . . . . . . . . . . . . . . . 36 REFERENCES . . . . . . . . . . . . . . . . . . 38 APPENDICES . . . . . . . . . . . . . . . . . . 40 APPENDIX A: Review of the Literature . . . . . . . . 41 What is Athletic Training? . . . . . . . . . . . 43 Certified Athletic Trainers in High Schools Injuries in the High School Setting Massachusetts Budgets . . . . 45 . . . . . 48 . . . . . . . . . . . . . . . . 51 . . . . . . . . . . . . . . . . . 51 Health Care . . . . . . . . . . . . . . . . 53 Summary . . . . . . . . . . . . . . . . . . . 54 APPENDIX B: The Problem . . . . . . . . . . . . . 57 Statement of the Problem . . . . . . . . . . 58 Definition of Terms . . . . . . . . . . . . . 59 Basic Assumptions . . . . . . . . . . . . . . 59 Limitations of the Study . . . . . . . . . . . 60 Significance of the Study. . . . . . . . . . . 60 APPENDIX C: Additional Methods . . . . . . . . . . 62 Panel of Experts Letter (C1) . . . . . . . . . . 63 High School Certified Athletic Trainer Availability Survey (C2) . . . . . . . . . . . . . . . . . 65 Institutional Review Board (C3) . . . . . . . . . 70 Cover Letter to Participants REFERENCES (C4) . . . . . . . . 81 . . . . . . . . . . . . . . . . . 84 vi ABSTRACT . . . . . . . . . . . . . . . . . . . 89 vii LIST OF TABLES Tables Page 1. Certified Athletic Trainers at High Schools. . . . . 11 2. Medical Personnel Providing Athletic Health Care . . . 11 3. Number of Certified Athletic Trainers at High Schools . 12 4. Years ATC has Worked at High Schools. . . . . . . . 12 5. Certified Athletic Trainers at High Schools. . . . . 12 6. Hours Per Week Worked By ATC s. . . . . . . . . . . 13 7. Why High Schools Do Not Have an ATC . . . . . . . . 13 8. Satisfaction with Medical Coverage. . . . . . . . . 14 9. Type of Institution . . . . . . . . . . . . . . 14 10. Divisional Classification 11. Boys’ Varsity Sports . . . . . . . . . . . 15 . . . . . . . . . . . . . 16 12. Girls’ Varsity Sports . . . . . . . . . . . . . 17 13. Practice Coverage by Certified Athletic Trainer . . . 18 14. Game Coverage by Certified Athletic Trainer . . . . 19 15. Athletic Budgets . . . . . . . . . . . . . . . 20 16. A MANOVA for Athletic Budget, Girls’ Varsity Sports, and Boys’ Varsity Sports . . . . . . . . . . . . 22 17. Pearson Correlation Between Athletic Budget, Boys’ Varsity Sports, and Girls’ Varsity Sports . . . . . 26 viii LIST OF FIGURES Figures Page 1. Boys’ Varsity Sports Versus Girls’ Varsity Sports . . . 17 2. Employing a Certified Athletic Trainer Based Upon the Number of Girls’ Varsity Sports . . . . . . . . . . 23 3. Employing a Certified Athletic Trainer Based Upon Athletic Budget . . . . . . . . . . . . . . . . 24 4. Scatterplot Comparing Boys’ Varsity Sports Teams with Girls’ Varsity Sports Teams . . . . . . . . . . . . 27 5. Scatterplot Comparing Boys’ Varsity Sports Teams with Athletic Budget . . . . . . . . . . . . . . . . 28 6. Scatterplot Comparing Girls’ Varsity Sports Teams with Athletic Budget . . . . . . . . . . . . . . . . 29 1 INTRODUCTION When athletes sustain athletic injuries, the certified Athletic Trainer is the first person of contact on the sports medicine team to evaluate the athlete and injury. A certified Athletic Trainer is a sports medicine professional who collaborates with physicians to optimize patient and client activity and participation in athletics, work, and life.1-3 Certified Athletic Trainers are properly educated and trained in the area of sports medicine and have the ability, thus qualifying them to recognize and treat athletic injuries seen at various levels of competition. At a minimum, to become a certified Athletic Trainer, one must hold a bachelor’s degree and pass a national certification examination specific to the competencies of a certified Athletic Trainer outlined by the National Athletic Trainers’ Association (NATA) and The Board of Certification (BOC).4 To maintain certification, certified Athletic Trainers must attend workshops or complete courses yearly and earn 80 continuing education units in a three year period. Certified Athletic trainers are well educated professionals in the field of sports medicine prepared to prevent, evaluate, rehabilitate, and manage athletic injuries at any given participation level 2 (i.e., high school, college, professional, elite, etc.). In fact, nearly 70% hold a master’s degree or higher advanced degree.4 High school sports participation is nearly 20 times greater than NCAA participation,5 and in 2005, more than 7 million high school students were participating in interscholastic athletics in the United States.6 With the large number of students involved in athletics, injuries sustained during practices and competition are inevitable. In the 2005-2006 school year alone; athletes participating in football, soccer, basketball, wrestling, volleyball, baseball, and softball sustained an estimated 1.4 million injuries.7 Injuries sustained by high school athletes have resulted in 500,000 doctor visits, 30,000 hospitalizations and a total cost to the healthcare system of nearly 2 billion dollars per year.8 While participating in athletics can be beneficial, children are getting injured at a very high rate in the secondary school setting. If a high school athlete sustains an injury and his or her family cannot afford insurance, what option do they have for treatment? Employing a certified Athletic Trainer at all high schools could help reduce doctor visits because a certified Athletic Trainer would be able to differentiate between 3 acute injuries and injuries that require a referral for more specialized medical attention. One study examined that there is an average of 2.6 million emergency department visits for sports-related injuries per year.9 A certified Athletic Trainer in the high school could provide that uninsured child initially with the appropriate medical attention they deserve, thus reducing the number of visits to the emergency room and medical costs. Many Americans struggle with paying for health insurance for themselves and their families. For example, in the 2008 tax year, about 50,000 Massachusetts residents were still without health insurance because they could not afford it.10 About 55% of Massachusetts residents stated that there was a time in 2009 that they needed medical care, tests, or treatments but were unable to get them due to being uninsured. Even though Massachusetts has tried to introduce legislature to insure every resident, there is still a significant amount of people living with no health insurance. With the overwhelming number of student-athletes at the high school level, athletic health care should be accessible to every child participating in athletic competition. Certified Athletic Trainers can provide effective athletic health care and should be available for 4 athletes at every high school in the United States. However, many high schools across the country do not employ a certified Athletic Trainer. In fact, as of 1999, Hawaii was the only state in the United States that required a certified Athletic Trainer to be employed at all public high schools.11 Certified Athletic Trainers are highly educated medical professionals that can provide exceptional care to athletes of all ages and may help many of these families without health care receive appropriate medical attention without the high costs. It is not unreasonable to think that a high percentage of certified Athletic Trainers would be employed at the secondary school level. However, according to the NATA only 42% of high schools have access to a certified Athletic Trainer12 and according to the NATA, about 21 percent of NATA members provide service to secondary schools.13 This study will attempt to answer the following questions: 1) Is having a certified Athletic Trainer in Massachusetts dependent on school divisional classification (I, II, III, IV)? 2) Are high schools with a higher athletic budget more likely to employ a certified Athletic Trainer than high schools with lower athletic budgets? and 3) Are high schools with more varsity sports teams more likely to employ a certified Athletic Trainer than high 5 schools with less varsity sports teams for A) boys’ and B) girls’? 6 METHODS This section includes the following subsections: Research Design, Subjects, Preliminary Research, Instrument, Procedures, Hypotheses, and Data Analysis. Research Design A descriptive design was used in this study. The dependent variables in this study were the athletic budget of the high schools and the number of varsity sports at the high schools. The independent variables of this study were high schools with or without a certified Athletic Trainer and the school’s divisional classification (I, II, III, IV). The strength of this study is that content validity was established for the survey after a review by a panel of experts. The limitation of this study was that only athletic directors in high schools in Massachusetts were surveyed. 7 Subjects The number of subjects for this study was 44 out of 371 athletic directors at public and private high schools in Massachusetts for a return rate of 11.8%. Sampling included the entire population of athletic directors in Massachusetts. Informed consent was implied with completion and return of the survey. Preliminary Research A review of the survey was conducted by a panel of experts (Appendix C1). This panel reviewed the survey and provided suggestions for improvements and changes. The panel includes a college sports medicine Program Director, a high school Athletic Director and a head high school certified Athletic Trainer. Instrument The High School Certified Athletic Trainer Availability Survey (Appendix C2) was used in this study and was available for the Athletic Directors to complete on www.surveymonkey.com. This survey was developed by the 8 researcher for the purpose of determining the prevalence of certified Athletic Trainers in high schools in Massachusetts. The survey asked for information regarding athletic training coverage by a certified Athletic Trainer at the school. There were questions regarding the amount of hours per week a school’s certified Athletic Trainer works and how many full time and part time certified Athletic Trainers are employed at the high school. The Athletic Director indicated the number and type of varsity sports teams and provided information regarding the athletic budget. There were a total of 16 questions the Athletic Directors completed in the survey. Procedures The survey was finalized after review by a panel of experts. An application was sent to California University of Pennsylvania’s Institutional Review Board for Protection of Human Subjects (Appendix C3) for approval before the study was conducted. A survey was created by the researcher and was sent electronically to 371 high school Athletic Directors in Massachusetts. The researcher contacted the President of the Massachusetts Secondary Schools Athletic Directors Association (MSSADA) to 9 distribute the survey to all Massachusetts high school Athletic Directors via email. Martha Jamieson, MSSADA President, granted Chris Aufiero, association Secretary, permission to distribute the survey. A Cover Letter to Participants (Appendix C4) was sent explaining the purpose of the study to the Athletic Directors and a link was also provided to access the survey. The researcher did not have the email addresses of the Athletic Directors, therefore responses were anonymous. The researcher allowed the Athletic Directors time to complete and return the survey. The Athletic Directors were sent a second email 7-10 days after the initial email as a reminder to complete the survey before the indicated deadline. Hypotheses These hypotheses were formed based on the literature review and the theories of the researcher. H1: Having a certified Athletic Trainer will be dependent on the school’s divisional classification (division I, division II, division III, division IV). H2: High schools with a higher athletic budget will be more likely to employ a certified Athletic Trainer than high schools with a lower athletic budget. 10 H3: High schools with more varsity sports teams will be more likely to employ a certified Athletic Trainer than high schools with less varsity sports teams for A) boys and B) girls. Data Analysis The level of significance was set at 0.05. H1: A 2 (Having a certified Athletic Trainer – yes/no) X 4 (School divisional classification- division I, II, III, IV) Chi square test of independence was used to determine if having a certified Athletic Trainer was dependent on a school’s divisional classification. H2 and H3: A MANOVA test was used to determine if high schools with higher athletic budgets were more likely to employ a certified Athletic Trainer than high schools with lower athletic budgets and if high schools with more varsity sports teams were more likely to employ a certified Athletic Trainer than high schools with less varsity sports teams for A) boys and B) girls. 11 RESULTS Demographic Data Massachusetts high school Athletic Directors (N = 44), which was a response rate of 11.9%, voluntarily participated in this survey. Table 1 represents the certified Athletic Trainers employed at high schools. Over half of the Athletic Directors that responded stated they have a certified Athletic Trainer at their high school. Table 1. Certified Athletic Trainers at High Schools Characteristic Frequency Percent Yes 25 56.8 No 18 40.9 Other 1 2.3 Table 2 represents the medical personnel that the Athletic Directors reported provided athletic health care to their athletes if they did not employ a certified Athletic Trainer. The most common medical personnel that the Athletic Directors indicated cared for their student athletes were EMTs. Table 2. Medical Personnel Providing Athletic Health Care Characteristic Frequency Percent EMT 17 38.6 Nurse 13 29.5 Coach 13 29.5 Physician 4 9.1 12 Table 3 shows the number of certified Athletic Trainers employed at the Massachusetts high schools, as indicated by the Athletic Directors. Some schools reported that they had no certified Athletic Trainer, while one school’s Athletic Director indicated that they had 20. Table 3. Number of Certified Athletic Trainers at High Schools Classification Min. Max. Mean SD Number of ATC 0 20 1.14 3.041 Table 4 represents the number of years that each high school has employed a certified Athletic Trainer. The highest number of years that a high school employed a certified Athletic Trainer was 33 years. Table 4. Years ATC has Worked at High School Classification Min. Max. Mean Years 0 33 9.08 SD 9.705 Table 5 represents the certified Athletic Trainer employed at high schools full-time and part-time. More schools employed a part-time certified Athletic Trainer over a full-time. There were twice as many part-time certified Athletic Trainers as compared to full-time. Table 5. Certified Athletic Trainers at High Schools Characteristic Frequency Percent Part-time 26 59.1 Full-time 13 29.5 No Response 5 11.4 13 Table 6 represents the approximate hours worked by the certified Athletic Trainers at the high schools. The most hours worked by a certified Athletic Trainer per week was approximately 50 hours. Table 6. Hours Per Week Worked By ATC Classification Min. Max. Hours 0 50 Mean 23.53 SD 16.761 Table 7 identifies the reasons why 27.27% of high schools may not employ a certified Athletic Trainer. The primary reason for a high school to not employ a certified Athletic Trainer was that they did not have enough money in their budget. One Athletic Director in particular stated that the administration at his/her school did not realize the importance of having a certified Athletic Trainer on staff. Table 7. Why High Schools Do Not Have an ATC Characteristic Frequency Not enough money 7 Care provided by other personnel 3 No affiliation with local clinic 1 Other 1 Have ATC 32 Percent 58.3 25.0 8.3 2.3 6.1 Massachusetts high school Athletic Directors were asked to report if they were satisfied with the medical professionals that provided athletic health care to their student-athletes. Over 50 percent of Athletic Directors 14 indicated that they were satisfied with the medical professionals that provided their student athletes with athletic health care. (See Table 8). Table 8. Satisfaction with Medical Coverage Characteristic Frequency Yes 24 No 10 Other 10 Percent 54.5 22.7 22.8 The Athletic Directors were asked to state whether their high school was a public or private institution. Only 11% Athletic Directors indicated that their school was private, while 65.9% schools were public institutions. (See Table 9). Table 9. Type of Institution Characteristic Public Private Other Frequency 29 5 10 Percent 65.9 11.4 22.7 The Athletic Directors were asked to report the divisional classification for their high school. They were asked to indicate either division I, division II, division III, or division IV on the survey. division was division I. The most common In Massachusetts, division I schools are the largest while division IV are the smallest. (See Table 10). 15 Table 10. Divisional Classification Characteristic Frequency Division I 12 Division III 9 Division II 7 Division IV 6 Other 10 Percent 27.3 20.5 15.9 13.6 22.7 Table 11 represents the number of boys’ varsity sports at the high schools. In the same question, the Athletic Directors also indicated the sports for their high school. The most boys’ varsity sports as reported by the Athletic Directors were 36 sports teams. Some Athletic Directors indicated that they had additional sports than those provided, which included sailing, Alpine skiing, cheerleading, cross country, crew, cross country skiing, Nordic skiing, and fencing. One Athletic Director stated that they had no boys’ varsity sports teams because his/her institution was an all girls’ school. 16 Table 11. Boys’ Varsity Sports Classification Min. Max. Number of boys’ sports 0 36 Characteristic Baseball Basketball Soccer Football Outdoor Track Golf Tennis Ice Hockey Indoor Track Wrestling Swimming/Diving Lacrosse Volleyball Gymnastics Field Hockey Mean 11.97 Frequency 30 30 29 28 28 27 24 22 20 19 17 15 13 4 2 SD 7.460 Percent 68.2 68.2 65.9 63.6 63.6 61.4 54.5 50.0 45.5 43.2 38.6 34.1 29.5 9.1 4.5 The Athletic Directors were asked to specify how many girls’ varsity sports teams they had at their high school. They also indicated which girls’ varsity sports they had. The highest number of girls’ varsity sports at the high schools was 18 teams. Some Athletic Directors reported additional sports teams than those provided, which included cheerleading, cross country, Nordic skiing, Alpine skiing, crew, fencing, dance, and sailing. (See Table 12). 17 Table 12. Girls’ Varsity Sports Classification Min. Max. Number of girls’ sports 5 18 Characteristic Soccer Softball Basketball Outdoor Track Tennis Volleyball Field Hockey Indoor Track Swimming/Diving Lacrosse Golf Gymnastics Ice Hockey Skiing Wrestling Frequency 33 33 32 31 28 26 23 23 22 20 14 13 13 12 4 Mean 11.27 SD 3.752 Percent 75.0 75.0 72.7 70.5 63.6 59.1 52.3 52.3 50.0 45.5 31.8 29.5 29.5 27.3 9.1 Figure 1. Boys’ Varsity Sports Versus Girls’ Varsity Sports 18 Table 13 shows the varsity sports that have coverage by a certified Athletic Trainer at their practices. Some Athletic Directors stated that they had practice coverage at sports like cheerleading, cross country, sailing, Nordic skiing, and Alpine skiing. Table 13. Practice Coverage by Certified Athletic Trainer Characteristic Frequency Percent Football 20 45.5 Girls Basketball 18 40.9 Girls Soccer 18 40.9 Girls Outdoor Track 17 38.6 Boys Basketball 16 36.4 Softball 16 36.4 Boys Outdoor Track 16 36.4 Baseball 15 34.1 Boys Soccer 15 34.1 Girls Field Hockey 14 31.8 Girls Lacrosse 14 31.8 Boys Lacrosse 13 29.5 Girls Volleyball 13 29.5 Girls Indoor Track 12 27.3 Boys Wrestling 12 27.3 Girls Tennis 11 25.0 Boys Outdoor Track 11 25.0 Boys Tennis 10 22.7 Boys Volleyball 7 15.9 Boys Swimming/Diving 5 11.4 Girls Swimming/Diving 5 11.4 Girls Gymnastics 4 9.1 Boys Ice Hockey 3 6.8 Girls Ice Hockey 3 6.8 Boys Golf 2 4.5 Girls Golf 2 4.5 Boys Gymnastics 2 4.5 Girls Wrestling 2 4.5 Boys Field Hockey 1 2.3 Boys Skiing 1 2.3 Girls Skiing 1 2.3 19 Table 14 shows the varsity sports that have coverage by a certified Athletic Trainer at their games. The Athletic Directors also indicated sports like cheerleading, cross country, sailing, Nordic skiing, and Alpine skiing had a certified Athletic Trainer covering their games or competitions. Table 14. Game Coverage by Certified Athletic Trainer Characteristic Frequency Percent Football 24 54.5 Girls Basketball 24 54.5 Boys Basketball 21 47.7 Girls Soccer 20 45.5 Boys Ice Hockey 19 43.2 Softball 19 43.2 Baseball 18 40.9 Girls Lacrosse 18 40.9 Boys Soccer 18 40.9 Girls Outdoor Track 17 38.6 Girls Field Hockey 16 36.4 Boys Lacrosse 16 36.4 Boys Outdoor Track 16 36.4 Boys Wrestling 16 36.4 Girls Volleyball 16 36.4 Girls Tennis 14 31.8 Girls Ice Hockey 12 27.3 Boys Tennis 11 25.0 Girls Indoor Track 11 25.0 Boys Indoor Track 10 22.7 Boys Volleyball 8 18.2 Girls Gymnastics 7 15.9 Boys Swimming/Diving 4 9.1 Girls Swimming/Diving 4 9.1 Girls Skiing 2 4.5 Girls Wrestling 2 4.5 Boys Golf 1 2.3 Girls Golf 1 2.3 Boys Gymnastics 1 2.3 Boys Skiing 1 2.3 20 The Athletic Directors were asked to report their school’s athletic budget. The highest athletic budget indicated was $1,000,000 by one Athletic Director. (See Table 15). Table 15. Athletic Budgets Classification Min. Max. Athletic Budget 45,000 1,000,000 Mean 373,007.93 SD 272,546.125 21 Hypotheses Testing The hypotheses were tested at a level of 0.05. Hypothesis 1: A chi square test of independence was used to determine if having a certified Athletic Trainer was dependent on the school’s divisional classification (DI, DII, DIII, DIV). Conclusion: There were not enough subjects to run the data analysis. Hypotheses 2 & 3: A MANOVA test was used to determine if high schools with higher athletic budgets were more likely to employ a certified Athletic Trainer than high schools with lower athletic budgets and if high schools with more varsity sports teams were more likely to employ a certified Athletic Trainer than high schools with less varsity sports teams for A) boys’ and B) girls’. Conclusion: A MANOVA was calculated examining if high schools with a higher athletic budget were more likely to employ a certified Athletic Trainer than high schools with lower athletic budgets and if high schools with more varsity sports teams were more likely to employ a certified Athletic Trainer than high schools with less varsity sports teams for A) boys’ and B) girls’. A significant effect was 22 found (Lambda(3,25)=.680, p=.020). Follow-up univariate ANOVAS indicated that employing a certified Athletic Trainer significantly improved with high athletic budgets (F(1,27)=7.406, p=.011) and employing a certified Athletic Trainer significantly improved with more girls’ varsity sports (F(1,27)=11.677, p=.002). No significant effect was found (F(1,27)= 3.200, p >.05) when examining if high schools with more boys’ varsity sports were more likely to employ a certified Athletic Trainer. Table 16. A MANOVA for Athletic Budget, Girls’ Varsity Sports, and Boys’ Varsity Sports Source Dependent Type III df MS F Variable Sum of Squares AB* 4.477E11 1 GVS* 130.072 1 BVS* 170.354 1 * AB (Athletic Budget), GVS (Girls’ (Boys’ Varsity Sports) 4.477E11 7.406 22596.891 11.677 170.354 3.200 Varsity Sports), P .011 .002 .085 BVS 23 YES NO Figure 2. Employing a Certified Athletic Trainer Based Upon the Number of Girls’ Varsity Sports 24 YES NO Figure 3. Employing a Certified Athletic Trainer Based Upon Athletic Budget 25 Additional Findings Table 17 displays a Pearson correlation between athletic budget of the high schools, the amount of boys’ varsity sports, and girls’ varsity sports. A moderate correlation was found (r(31)=.480, p < .005) between the number of boys’ varsity sports and the number of girls’ varsity sports. A strong positive correlation was found (r(27)=.751, p < .001) between the athletic budget and the number of boys’ varsity sports, indicating a significant linear relationship between the two variables. This indicates that schools with higher athletic budgets tended to have more boys’ varsity sports teams. A moderate positive correlation was found (r(27)= .664, p < .001) between the athletic budget and girls’ varsity sports. 26 Table 17. Pearson Correlation Between Athletic Budget, Boys’ Varsity Sports, and Girls’ Varsity Sports BVS* GVS* AB* BVS Pearson Sig(2tail) N GVS Pearson .480 Sig(2tail) .005 N 33 AB Pearson .751 .664 Sig(2tail) .000 .000 N 29 29 *BVS (Boys’ Varsity Sports), GVS (Girls’ Varsity Sports), AB (Athletic Budget) 27 Figure 4. Scatterplot Comparing Boys’ Varsity Sports Teams with Girls’ Varsity Sports Teams. 28 Figure 5. Scatterplot Comparing Boys’ Varsity Sports Teams with Athletic Budget. 29 Figure 6. Scatterplot Comparing Girls’ Varsity Sports Teams with Athletic Budget. 30 DISCUSSION The following section will include: 1) Discussion of Results, 2) Conclusions, and 3) Recommendations. Discussion of Results This study focused on certified Athletic Trainers employed at high schools in the Commonwealth of Massachusetts. Certified Athletic Trainers are trained medical professionals that can provide athletes of all ages with appropriate athletic health care. Many high schools across the country do not employ a certified Athletic Trainer and need someone they can rely on to care for their student-athletes. In 2005, more than 7 million high school students were participating in interscholastic athletics in the United States.6 Even with this significantly high amount of students participating in athletics at the secondary school level, according to the National Athletic Trainers’ Association only 42% of high schools have access to a certified Athletic Trainer.12 As of 1999, Hawaii was the only state in the Unites States that required a certified Athletic Trainer to be employed at all public high 31 schools.11 With so many high school participants, there needs to be a medical professional available to these athletes to provide effective athletic health care when injuries occur. It was found that 56.8% of the 44 high school Athletic Directors in the commonwealth of Massachusetts that participated in this study have a certified Athletic Trainer on staff. Over half (51.9%) are full-time employees while 29.5% are part-time employees. Health care coverage has become a growing issue for many Americans. In Massachusetts, about 50,000 residents in the 2008 year were still without any type of health care coverage.10 Even though legislation was introduced in the state in order to ultimately cover every resident, there are still significant amounts of people without health care coverage. These people without health insurance need to have somewhere to turn when faced with athletic injuries. Having a certified Athletic Trainer at every high school could help those people without any health coverage get the medical attention they need. A certified Athletic Trainer at their institution could help those people without any health insurance and could have somewhere to turn when faced with an injury. This study tried to determine if having a certified Athletic Trainer was dependent on the school’s divisional 32 classification (DI, DII, DIII, DIV). However, with only 44 Athletic Directors responding to the survey, there was not enough data to run an analysis. Division I schools in Massachusetts are the largest class of schools, so it’s not surprising to see that they are more likely to have a certified Athletic Trainer as opposed to smaller schools. In other studies such as Biddington et al,14 it was found that class AAAA, being the largest in the state of Pennsylvania, were more likely to employ a certified Athletic Trainer as opposed to smaller schools. The results from this study found that schools with higher athletic budgets were more likely to hire a certified Athletic Trainer. This finding suggests that schools that have more money allotted to their athletic program will probably have extra money to put towards additional costs such as hiring a certified Athletic Trainer. It was also found that employing a certified Athletic Trainer significantly improved with more girls’ varsity sports. Emerging evidence indicates that female high school and college athletes in basketball, soccer, lacrosse, field hockey, and skiing experience a greater number of knee and ankle injuries than their male counterparts.15 This may suggest why schools with a higher number of girls’ varsity sports teams may be more likely to 33 have a certified Athletic Trainer. However, high schools with a higher number of boys’ varsity sport were not likely to have a certified Athletic Trainer. It was believed that having a certified Athletic Trainer would be dependent on the number of varsity sports at a high school because with more athletes, there will be more injuries and therefore more need for someone readily available to student-athletes to care for their injuries. This study asked Athletic Directors to indicate which sports had coverage by certified Athletic Trainers at practices and games. During practices, the sport with the most coverage is football at 45.5%. This seems like an appropriate result since football is considered a high contact sport. However, boy’s ice hockey only had 6.8% of coverage at practices. Boy’s ice hockey is another high contact sport and should have a certified Athletic Trainer at practices at a higher percentage. For game coverage, football was again the highest at 54.5% of coverage by a certified Athletic Trainer. However, girls’ basketball has the same percentage while higher contact sports like boys’ ice hockey and boys’ lacrosse have lower percentages. A strong correlation was found between athletic budgets and the number of boys’ varsity sports, indicating that high schools with higher athletic budgets tended to 34 have more boys’ varsity sports teams. A moderate correlation was found between athletic budgets and girls’ varsity sports. These results show that the more sports a school has, the more money they will need. A moderate correlation was found between boys’ varsity sports and girls’ varsity sports. This may show that schools are trying to offer the same opportunities to both boys and girls regardless of school size. In regards to the correlation between boys’ varsity sports and girls’ varsity sports, it was stated that the maximum amount of boys’ varsity sports teams was 36, while the maximum amount of girls’ varsity sports was 18. Schools were generally equal in their boys’ and girls’ sports, where the 36 boys’ sports could have been an outlier. Title IX legislation states that girls and women in high school and college should have the same opportunities.16 These results reflect how Title IX has helped girls’ high school sports because the girls seem to have the same opportunity as boys. 35 Conclusions After reviewing the results of this study, it can be concluded that high schools in Massachusetts are taking it upon themselves to recognize the need for certified Athletic Trainers at the secondary school level. There is no legislation in the state requiring high schools to employ a certified Athletic Trainer, however over half of the high schools surveyed have one on staff. Of the schools that responded to the study, more division I high schools have certified Athletic Trainers as opposed to division IV, which is the smallest in Massachusetts. While it may be difficult due to budget restraints, smaller schools need to start employing certified Athletic Trainers. One area which needs improvement is coverage of higher contact sports by each school. There can be devastating injuries during high contact sports competition and there needs to be someone there during play who can aid in helping injured student-athletes. When asked if satisfied with the medical coverage at their high school, more than half of the Athletic Directors participating in this survey responded that they were. Even though high schools in the state are still without a certified Athletic Trainer, the 36 56.8% of the 44 high schools participating in this study that employ a certified Athletic Trainer are pleased with the services they provide to the student-athletes. Recommendations The purpose of this study was to see how many high schools in Massachusetts employed a certified Athletic Trainer. After reviewing the results, a recommendation to Massachusetts would be to introduce legislation that would require all high schools to have a certified Athletic Trainer on staff. To perhaps gain better and more accurate results, a study on this same state with a higher response rate may be necessary. Only 44 (11.9%) of the 371 Athletic Directors contacted to participate in this study completed the survey and therefore a study with more responses may prove more accurate. It would also be beneficial for future studies to examine other states and their high school athletic health care coverage. Studying more states will give us a better picture of certified Athletic Trainers working at the high school level and which states have better coverage as opposed to others. 37 Choosing another population to sample may provide researchers with better response rates. This study asked Athletic Directors to respond to a survey about athletic health care at their high schools and there was a low response rate of only 11.9%. Sampling another population might garner high results since Athletic Directors may not have all the information when it comes to certified Athletic Trainers. There may be other personnel in the high school who could provide more accurate results and hopefully higher response rates. Future research can focus on state sizes and comparing if bigger states have more high school certified Athletic trainers as opposed to smaller states. 38 REFERENCES 1. National Athletic Trainers Association. Athletic training services. Available at: http://nata.org/sites/default/files/GuideToAthleticTra iningServices.pdf. Accessed June 29, 2010. 2. Board of Certification. What is an athletic trainer? Available at: http://www.bocatc.org. Accessed on June 29, 2010. 3. Board of Certification. Defining athletic training. Available at: http://www.bocatc.org/athtrainer/DEFINE. Accessed September 13, 2010. 4. National Athletic Trainers Association. The facts about athletic trainers. Available at: http://nata.org/sites/default/files/AT_facts.pdf. Accessed December 7, 2010. 5. Claiborne T, Hou S, Cappaert T. Certified athletic trainers provide effective care in the high school setting. Athletic Therapy Today. 2007;12(2):34-38. 6. Almquist J, McLeod TC, Cavanna A, et al. Summary statement: Appropriate medical care for the secondary school aged athlete. J Athl Train. 2008;43(4):416-427. 7. Yard EE, Collins CL, Comstock RD. A comparison of high school sports injury surveillance data reporting by certified athletic trainers and coaches. J Athl Train. 2009;44(6):645-652. 8. Adirim TA, Cheng TL. Overview of injuries in the young athlete. Sports Med 2003;33(1):75-81. 9. Burt CW, Overpeck MD. Emergency visits for sportsrelated injuries. Ann Emerg Med 2001;37(3):301-6. 39 10. Health connector, health insurance for Massachusetts residents: health reform facts and figures fall 2010. Available at: https://www.mahealthconnector.org/portal/site/connecto r/menuitem.d7b34e88a23468a2dbef6f47d7468a0c?fiShown=de fault. Accessed October 26, 2010. 11. Nichols AW. The role of athletic trainers and physical therapists in sports medicine. Hawaii Med J. 1999(58):81-82. 12. National Athletic Trainers Association. Athletic trainers fill a necessary niche in secondary schools. Available at: http://nata.org/NR031209. Accessed December 10, 2010. 13. National Athletic Trainers Association. Secondary School Setting. Available at: http://www.nata.org/athletic-training/jobsettings/secondary-schools-setting. Accessed April 12, 2011. 14. Biddington C, Wagner RW, Lyles A, Brunner M. Athletic health care in Pennsylvania high schools. Pennsylvania J Health Physical Education Recreation Dance. 2009;2022. 15. Whiteside P. Men’s and women’s injuries in comparable sports. Phys Sportsmed. 1980;8(3):130-40. 16. Women’s Sports Foundation. Understanding Title IX and Athletics 101. Available at: http://www.womenssportsfoundation.org/Issues-AndResearch/Title-IX.aspx. Accessed March 2011. 40 APPENDICES 41 APPENDIX A Review of the Literature 42 Review of the Literature Certified Athletic Trainers work in a variety of health care settings. The secondary school setting is commonly overlooked as an environment for employment of an Athletic Trainer often attributed to budget restraints or location of the school. While some high schools do have a full time certified Athletic Trainer on staff, many schools located throughout the United States may rely on services provided by volunteer physicians, chiropractors, physical therapists, and other such health care professionals who do not specialize in appropriate sports medicine techniques. High school student participation in athletics has grown significantly and a growing need for certified Athletic Trainers in high schools to provide medical care to injured athletes should follow. Massachusetts, like many states have no current laws requiring certified Athletic Trainers to work in every high school. With the large increase in athletic participation, more and more high schools will start to need certified Athletic Trainers to care for injured student-athletes. The topics that will be discussed include: (1) What is Athletic Training? (2) Athletic Trainers in High Schools, (3) Injuries in the High School Setting, and (4) 43 Massachusetts. Massachusetts will also include two subsections: Budgets and Health care. A summary of the review of the literature will also be included. What is Athletic Training? A certified Athletic Trainer is a sports medicine professional who collaborates with physicians to optimize patient and client activity and participation in athletics, work, and life.1 Certified Athletic Trainers specialize in six domains which include prevention, clinical evaluation and diagnosis, immediate care, treatment, rehabilitation and reconditioning, organization and administration, and professional responsibility.2 The profession of athletic training is recognized by the American Medical Association as a healthcare profession.3 Athletic training educational programs are accredited by the Commission on Accreditation of Athletic Training Education (CAATE).2,3 Students spend four years in an undergraduate athletic training programs and become knowledgeable in a variety of areas such as assessment and evaluation, acute care, general medical conditions and disabilities, pathology of injury and illness, pharmacological aspects of injury and illness, nutritional 44 aspects of injury and illness, therapeutic exercise, therapeutic modalities, risk management and injury prevention, health care administration, professional development and responsibility, and psychosocial intervention and referral.3 Upon completion of an undergraduate program, students may sit for a national certification exam to become a certified Athletic Trainer. Many certified Athletic Trainers continue their education and about 70% hold a master’s degree or doctoral degree in athletic training or related areas such as exercise physiology, wellness and health promotion, or health care administration.4 Certified Athletic Trainers can work in a variety of settings including high schools, college, and sports medicine clinics.5 Certified Athletic Trainers have a unique education and set of skills that allow them to properly assess and treat acute and traumatic injuries in athletics.6 It is the belief of the National Athletic Trainers Association and many other governing medical bodies that injury situations at the high school level should not be handled by laypersons that do not possess the necessary skills in order to care for athletic injuries and therefore high schools nationwide should employ a certified Athletic Trainer.7 45 Certified Athletic Trainers in High Schools There has been a 98% increase in high school athletic participation between the years 1971 and 2005.8 With such a drastic jump in student involvement in extracurricular activities, certified Athletic Trainers in the secondary school setting needs to increase as well. The American Medical Association issued a statement that the athletic medicine unit of every high school should include an athletic health coordinator who is preferably a certified Athletic Trainer.9 A certified Athletic Trainer can reduce injury occurrences and help to prevent re-injuries, thus decreasing time lost from practice and game time. Full- time secondary school certified Athletic Trainers offer the additional benefit of being available during the school-day to assist the injured athlete with recovery by implementing the instructions from the team or personal physician for treatment of that injury.10 Providing these services on campus can help to reduce lost instructional time for the student athlete. However, As of 1999, Hawaii was the only state in the country that mandates athletic trainers in every public high school.11 Every state in the United States should have stricter regulations and laws that would require certified Athletic Trainers in every high school. 46 Appropriate medical care of the secondary school-aged individual involves more than basic emergency care during sports participation.12 Many schools throughout the country however rely on persons other than qualified sports medicine professionals to handle athletic injuries. Kentucky legislature has mandated that a coach from each team in high schools must undergo advanced emergency sports medicine training.13 Should parents feel that their children are in good hands because a coach has a certification that took them a few hours or weeks to complete, when they could have a certified Athletic Trainer, who has completed four or more years of school, caring for their children? Nurses are also being called in to care for students beyond normal school hours and are being put in charge of responding to athletic injuries. Nursing, as a profession, does not have an extensive knowledge of injury prevention or assessment of orthopaedic injuries provided during basic nursing education.14 Certified Athletic Trainers are well educated in the prevention of athletic injuries and how to properly evaluate and assess athletic injury situations. The health, safety, and well-being of those participating in high school athletics should be the priority of high schools nationwide and therefore adequate personnel should 47 be on site to ensure that injuries are recognized early, treated immediately, and allowed to heal properly.15 As high school athletics grow, the need for certified Athletic Trainers to tend to athletic injuries grows as well. In a recent study, athletic health care coverage in Pennsylvania found that 88.4% of high schools stated that they had access to a certified Athletic Trainer.16 Even with this number being relatively high, there were 17% of schools without certified Athletic Trainers. It was also concluded that public schools were more likely to have certified Athletic Trainers compared to private. A study identified the preparedness among Illinois high school athletic departments, 73% of schools had a certified Athletic Trainer.17 It was also found that 32% of schools reported having coverage at practices, while 50% of schools had coverage at games. A study that examined medical coverage in California revealed that 62% of high schools reported some form of a certified Athletic Trainer on campus either full time or part time.18 A study examining medical coverage of high schools in North Carolina revealed that only 56% of schools had coverage by a state certified Athletic Trainer.19 No matter the type or size of high schools, a certified Athletic Trainer should be employed at every high 48 school in the United States. High schools should also not differentiate between practices or games, requiring a certified Athletic Trainer on school property at all times. The remaining 49 states should join Hawaii in mandating that certified Athletic Trainers be employed at all high schools in order to keep athletic participation safe for all student-athletes. Injuries in the High School Setting While the number of student-athletes in the secondary setting has been growing over the past few decades, the number of injuries sustained by participants has increased as well. The National Athletic Trainers’ Association estimates that about one-third of the 7.5 million students who play interscholastic sports will get hurt.20 Injuries sustained by high school athletes have resulted in 500,000 doctor visits, 30,000 hospitalizations and a total cost to the healthcare system of nearly 2 billion dollars per year.21 To deal with the high amount of injuries seen at the high school level, the Appropriate Medical Care for Secondary School-Aged Athletes Task Force (AMCSSAA) was developed in 2002 by the National Athletic Trainers’ Association to ensure young athletes were receiving 49 adequate medical care while participating in practices and games.22 The task force is responsible for addressing concerns like emergency care, prevention, and activities of ongoing daily athletic health care in the secondary school setting. One study examining ankle injuries among high school athletes found that approximately 326,396 ankles injuries occurred nationally in 2005-2006, yielding an injury rate of 5.23 ankle injuries per 10,000 athlete-exposures.23 Researchers found that sports that require jumping and quick movements resulted in higher incidences of ankle injuries. While this study mainly focused on football, soccer, volleyball, basketball, wrestling, baseball, and softball, it can be concluded that any sport will require jumping and fast movements and therefore, injuries can occur while participating in any sport. A certified Athletic Trainer who has been trained to handle athletic injuries should be a staple at all high schools. However, many schools that do not employ certified Athletic Trainers at their schools have to rely on others to care for athletes. This could be detrimental to athletes because not only are personnel like school nurses or coaches not educated to properly recognize and treat athletic injuries, they also do not possess the 50 knowledge to properly prevent injuries and later record information about them. A study examining the assessment of high school coaches’ knowledge of sports related concussions found that there is a need for educating coaches in all areas of sports related concussions, with particular emphasis placed on prevention and basic early management of sports related concussions.24 Certified Athletic Trainers are thoroughly educated on early prevention of injuries, while coaches may only attend various workshops to learn basic first aid knowledge of sports injuries. It is also an important aspect of all medical professions to document injuries that have been reported and record what treatment is given. One study examined the possibility of relying on coaches as data reporters, which found that only 43% of enrolled coaches completed necessary documents on injuries, but all enrolled certified Athletic Trainers participated.25 High schools should not have to rely on employees or outside volunteers who are not trained to properly handle athletic injury situations. 51 Massachusetts With physical activity participation in Massachusetts at 63%, the need for certified Athletic Trainers is a concern.26 There are 7,536,753 students in the United States participating in high school athletics, which represents 55.2% of all enrolled students.27 With this large amount of students participating in athletic activities, injuries are inevitable and should be cared for by certified Athletic Trainers. Many high schools across the country, including those in the Commonwealth of Massachusetts, are not always able to benefit from the services of a certified Athletic Trainer. Two thirds of the nation’s public school sports programs lack a fulltime, certified Athletic Trainer.28 Budgets Budgetary problems are often the main cause of high schools throughout the country lacking a full-time Athletic Trainer. MetroWest Medical Center in Massachusetts provides certified Athletic Trainers at a discount to seven high schools who do not already employ a certified Athletic Trainer. Still, this program is limited in the amount of certified Athletic Trainers they can lend out to area high 52 schools, with many of their employees working extra-long hours to cover high school athletic events. A high school in Bellingham, Massachusetts left the program when they hired a full-time certified athletic trainer several years ago. However, returned when budget cuts forced them to let go of their certified Athletic Trainer this year. Many schools around the state and country are faced with the same problem of a lack of athletic budgets to fund the hiring of a certified Athletic Trainer. Budgetary problems plague high school programs, but just as coaches are employed to develop skills and implement strategies, certified Athletic Trainers are required to ensure safety of the athletes and optimize their participation.29 While hiring a certified Athletic Trainer may pose an increased cost to a high school, having one on staff would be extremely beneficial. Many schools have compared the cost of treating their injured athletes at local clinics with treating them on-site under the supervision of an ATC. They have found that their certified Athletic Trainers are providing the equivalent to thousands of dollars of athletic training services per year to their athletes.30,31,32 These comparisons suggest that it is financially feasible and fiscally responsible to invest in employing a certified Athletic Trainer. 53 Health Care Health care coverage has been a growing issue among Americans in the past few years. In 2000, 83% of people ages 18 or older had health care coverage in the United States.33 Massachusetts is one of the few states that had a higher number of people 18 years or older with health care coverage at 92% in 2000. In 2006, Massachusetts introduced a healthcare reform effort to complement existing coverage programs.34 The goal was to provide near-universal coverage of the Massachusetts population. For tax year 2008, over 95% of tax filers were insured for the full year while 96.4% were insured at some point during the year, according to the Massachusetts Department of Revenue. An estimate by the Division of Health Care Finance and Policy published in October 2009 showed that 2.7% of Massachusetts residents remain uninsured as of spring of 2009. Even though this number may be lower than the national average of uninsured Americans, everyone in the United States should be able to benefit from health care. With the number of people in the Unites States still without health care, it becomes difficult to find ways to treat athletic injuries without paying too much to see a health care professional. Having certified Athletic Trainers in the high school setting allows adolescents to 54 be seen by a qualified health care professional without having to visit a hospital, clinic, or their personal physician, thus saving a co-pay or examination payment. In states with fewer certified Athletic Trainers, a greater share of injuries generally viewed as minor contusions, abrasions, and dislocations were likely sent to the emergency room than in states with more certified Athletic Trainers.35 Having someone trained to know what requires minor medical attention on site or what kind of injury requires a 911 call can make all the difference. Summary The review of literature focuses on what athletic training is, certified Athletic Trainers in high schools, injuries at the high school level, and budgets and health care in the Commonwealth of Massachusetts. Certified Athletic Trainers are allied health professionals that are well educated in sports medicine health care. Certified Athletic Trainers become knowledgeable in a variety of areas such as assessment and evaluation, acute care, general medical conditions and disabilities, pathology of injury and illness, pharmacological aspects of injury and illness, nutritional aspects of injury and illness, 55 therapeutic exercise, therapeutic modalities, risk management and injury prevention, health care administration, professional development and responsibility, and psychosocial intervention and referral.3 There should be a certified Athletic Trainer available to student-athletes at all high schools across the country. Only one state in the country currently requires certified Athletic Trainers in every high school, but all studentathletes should be able to benefit from certified Athletic Trainers. With the large amount of participation in athletics in the secondary school setting, injuries are an inevitable part of competition. Certified Athletic Trainers are skilled in providing health care to athletes and could help reduce and treat the injuries seen every year. Like many states, Massachusetts has problems putting certified Athletic Trainers in every high school due to budget constraints. Many schools have low athletic budgets and cannot afford to hire certified Athletic Trainers. Having a certified Athletic Trainer in a high school could help to reduce hospital visits because they can provide the appropriate care to student-athletes. While the initial hire of a certified Athletic trainer can cost a substantial amount for a high school, costs can be reduced in the long 56 run by providing athletic health care services free of charge on campus that were previously performed off campus and for a fee.30,31 Schools that currently employ certified athletic trainers have been able to show cost savings of as much as $70,000-$80,000/year to student-athletes and their families by providing on campus athletic training services. A certified Athletic Trainer is the most appropriate medical professional to have on staff at a high school to care for student-athletes. 57 Appendix B The Problem 58 The Problem Statement of the Problem Every student-athlete should have an equal opportunity to benefit from proper athletic health care when they are faced with an injury. In order to better serve student- athletes, a certified Athletic Trainer should be employed at every high school across the country. Certified Athletic Trainers have extensive backgrounds in sports medicine techniques, are nationally certified, and can be a vital addition to any high school athletic department. There are a significant number of adolescents that are participating in high school athletics and with that, there will inevitably be a high number of injuries. These injuries should not be left to an untrained individual. Certified Athletic Trainers are educated in providing initial injury assessment, first aid, rehabilitation, and can make return to play decisions. High schools should recognize the need for hiring medical personnel who can provide effective athletic heath care for their studentathletes. The purpose of this study is to examine the factors influencing the availability of certified Athletic Trainers in high schools in Massachusetts. 59 Definition of Terms The following terms have been identified for the purpose of this study: 1. Athletic heath care- health care that is provided to athletes. 2. Certified athletic trainer- a sports medicine professional who collaborates with physicians to optimize patient and client activity and participation in athletics, work, and life.1 These professionals have received a minimum of a bachelor’s degree and passed a national examination. 3. School divisional classification- based on the amount of students where division IV is the smallest and division I is the largest. Basic Assumptions There are several basic assumptions the researcher will use during this study. 1. The subjects will respond honestly to the survey. 2. The survey will have content validity after being reviewed by the panel of experts. 3. There will be a high rate of return because Athletic Directors care about their school’s athletic health care. 60 Limitations of the Study The following are possible limitations of the study: 1. Only Massachusetts high school Athletic Directors are participating in the study. 2. Some subjects may not respond to the survey. 3. The results will be restricted based on the questions asked in the survey. Significance of the Study With the significant amount of high school studentathletes, injuries are bound to occur. Certified Athletic Trainers should be employed by every high school in order to provide effective athletic health care to these studentathletes. Factors such as school divisional classification (I, II, III, IV), athletic budgets, and the number of varsity sports at a high school may have an affect on whether or not a certified Athletic Trainer is present at a school. Student-athletes deserve to have medical professionals who are thoroughly educated in providing effective athletic health care caring for them. High schools need to recognize the growing need for certified Athletic Trainers at the high school level. There is a high number of physically active individuals in the United States and high 61 school athletics should not be overlooked as an area in which sports medicine professionals such as certified Athletic Trainers should be hired. In Massachusetts like many other states, there are no laws requiring certified Athletic Trainers to work at every high school. By evaluating the factors which influence if a high school has a certified Athletic Trainer or not, it should help governing bodies improve laws and mandate certified Athletic Trainers be hired at every high school in Massachusetts. 62 Appendix C Additional Methods 63 Appendix C1 Panel of Experts Letter 64 December 2010 Dear_______________: I am a graduate athletic training student at California University of Pennsylvania pursuing a Master of Science degree in athletic training. To fulfill the thesis requirement for this program, I am conducting a descriptive study. The objective of this study is to determine the factors that influence whether high schools have a certified athletic trainer or not. In order to increase the content validity of the instrument, a panel of experts has been chosen to review the survey. You have been selected as one of the three professionals to be on this panel. Your feedback is vital to the success of this study. The information obtained by this panel of experts review will be used to make revisions and create the final survey to be distributed to the population sample. Your responses are voluntary and will be confidential. Please answer the following questions based on the attached survey and make any other additional comments you deem appropriate. Please return your comments and revisions via email no later than ____. If you have any questions or concerns, please do not hesitate to contact me. 1. Are the questions appropriate, valid, and understandable? Please Explain. 2. Comment on the overall presentation of the survey. 3. Which questions, if any, should be restated from the survey? Why? What suggestions would you make? 4. Which questions, if any, should be added to the survey? Why? What suggestions would you make? Thank you in advance for your time and efforts. Sincerely, Kathryn Annunziata, ATC California University of Pennsylvania 65 Appendix C2 High School Certified Athletic Trainer Availability Survey 66 High School Certified Athletic Trainer Availability Survey 1. Is there a certified Athletic Trainer employed at your high school? Yes No 2. If your high school does not have a certified Athletic Trainer, what medical professional provides athletic health care to your student-athletes? Please check all that apply. Physician Nurse Physician’s Assistant EMT Coach Physical Therapist None Other______________ 3. How many certified Athletic Trainers work at your high school?_____________ 4. How long has your school employed a certified Athletic Trainer?_____________ 5. Is your certified Athletic Trainer full-time or parttime? Full-time Part-time 6. If you have more than one certified Athletic Trainer, identify the number of full-time and part-time certified Athletic Trainers. Full-time Part-time 7. Approximately, how many hours a week do your certified Athletic Trainer(s) work at your high school? ______ 8. If your high school does not have a certified Athletic Trainer, please specify why not. Please check all that apply. Not enough money in budget Total number of varsity sports No affiliation with a local clinic Care provided by other personnel No place to house a certified Athletic Trainer Other_____________________________ 67 9. Are you satisfied with the number of medical personnel that provide athletic health care coverage to your student-athletes? Yes No 10. Is your high school public or private? Public Private 11. What is the divisional classification of your high school? I II III IV Other___________ 12. How many varsity boys’ sports does your high school have? _____________ Please indicate which varsity boys’ sports your high school has. Please check all that apply: Baseball Basketball Field Hockey Football Golf Gymnastics Ice Hockey Lacrosse Skiing 13. Soccer Swimming/Diving Tennis Indoor Track Outdoor Track Volleyball Wrestling Other____________ How many varsity girls’ sports does your high school have? _____________ Please indicate which varsity girls’ sports your high school has. Please check all that apply: Basketball Field Hockey Football Golf Gymnastics Ice Hockey Lacrosse Soccer Softball Swimming/Diving Tennis Indoor Track Outdoor Track Volleyball 68 Skiing 14. Which of these varsity sports have a certified Athletic Trainer providing athletic health care coverage during practices? Please check all that apply. Baseball Boys Basketball Girls Basketball Boys Golf Girls Golf Boys Field Hockey Girls Field Hockey Football Boys Gymnastics Girls Gymnastics Boys Ice Hockey Girls Ice Hockey Boys Lacrosse Girls Lacrosse Boys Skiing Girls Skiing 15. Wrestling Other____________ Softball Boys Soccer Girls Soccer Boys Swimming/Diving Girls Swimming/Diving Boys Tennis Girls Tennis Boys Indoor Track Girls Indoor Track Boys Outdoor Track Girls Outdoor Track Boys Wrestling Girls Wrestling Boys Volleyball Girls Volleyball Other____________ None Which of these varsity sports have a certified Athletic Trainer providing athletic health care coverage during games? Please check all that apply. Baseball Boys Basketball Girls Basketball Boys Golf Girls Golf Boys Field Hockey Girls Field Hockey Football Boys Gymnastics Girls Gymnastics Boys Ice Hockey Girls Ice Hockey Boys Lacrosse Girls Lacrosse Boys Skiing Softball Boys Soccer Girls Soccer Boys Swimming/Diving Girls Swimming/Diving Boys Tennis Girls Tennis Boys Indoor Track Girls Indoor Track Boys Outdoor Track Girls Outdoor Track Boys Wrestling Girls Wrestling Boys Volleyball Girls Volleyball 69 Girls Skiing 16. Other____________ None What is the total athletic budget of your high school? _____________ Please provide any additional comments: Approved by the California University of Pennsylvania IRB 70 APPENDIX C3 Institutional Review Board California University of Pennsylvania 71 72 73 74 75 76 77 78 79 80 IRB 10-034 approval instreviewboard Sent:Thursday, February 03, 2011 3:07 PM To: ANN2828 - ANNUNZIATA, KATHRYN NICOLE Cc: Biddington, Carol; Skwarecki, Robert Institutional Review Board California University of Pennsylvania Psychology Department LRC, Room 310 250 University Avenue California, PA 15419 instreviewboard@cup.edu instreviewboard@calu.edu Robert Skwarecki, Ph.D., CCC-SLP,Chair Ms. Annunziata , Please consider this email as official notification that your proposal titled “The Availability of Certified Athletic Trainers in High Schools in Massachusetts” (Proposal #10-034) has been approved by the California University of Pennsylvania Institutional Review Board as submitted. The effective date of the approval is 02-03-2011 and the expiration date is 02-02-2012. These dates must appear on the consent form. Please note that Federal Policy requires that you notify the IRB promptly regarding any of the following: (1) Any additions or changes in procedures you might wish for your study (additions or changes must be approved by the IRB before they are implemented) (2) Any events that affect the safety or well-being of subjects (3) Any modifications of your study or other responses that are necessitated by any events reported in (2). (4) To continue your research beyond the approval expiration date of 02-02-2012 you must file additional information to be considered for continuing review. Please contact instreviewboard@calu.edu Please notify the Board when data collection is complete. Regards, Robert Skwarecki, Ph.D., CCC-SLP Chair, Institutional Review Board 81 APPENDIX C4 Cover Letter to Participants 82 Dear Participants: I am a master’s degree candidate at California University of Pennsylvania, requesting your help to complete part of my degree requirements. There is a high number of studentathletes at the secondary school setting participating in athletics and there needs to be a medical professional readily available to them who is properly educated in caring for athletic injuries. Certified Athletic Trainers are trained to recognize and treat injuries sustained in the athletic setting. The results of this study (not including individual information) may be published in medical journals to inform the medical community of the factors that influence whether high schools in Massachusetts employ a certified Athletic Trainer. Massachusetts high school Athletic Directors have been chosen as the subjects for this study because the researcher feels they can accurately provide information about their school’s athletic health care coverage. Please follow the link at the end of this letter to an online survey titled: High School Certified Athletic Trainer Availability Survey. The questionnaire consists of 16 questions, which will take about 10 minutes to complete. Due to this being a survey there is minimal risk involved as confidentiality will be maintained. All Massachusetts high school Athletic Directors are being asked to complete this questionnaire, although you do have the right to choose not to participate or to discontinue participation at any time. If the participant chooses to discontinue the survey (by clicking the EXIT THIS SURVEY button on the top of the webpage) then all information will be discarded. The California University of Pennsylvania Institutional Review Board has approved this study for the Protection of Human Subjects. This approval is effective MM/DD/YEAR and expires MM/DD/YEAR. This is an anonymous questionnaire and upon submission, neither your name nor email address will be attached to your answers. Your information will be kept strictly confidential and it will only be accessible to the researcher. All survey information will be stored on a password protected online database that only the researcher will have access to. Upon completion of the study all 83 individual survey results will be deleted. By completion of the survey, you are giving the researcher consent to use the results of your survey in the study. As a Massachusetts high school Athletic Director, your information and opinions regarding this topic makes your input invaluable. Please take a few minutes to fill out the anonymous questionnaire you will find by clicking on this link: LINK If you have any concerns or questions please feel free to contact me through email at Ann2828@calu.edu or by phone at (203)444-1450. Thank you for your time and consideration. Sincerely, Kathryn Annunziata, ATC California University of Pennsylvania 250 University Avenue California, PA 15419 Ann2828@calu.edu (203)444-1450 Carol Biddington, EdD Faculty Advisor Exercise Science and Sport Studies Biddington@calu.edu 724-938-4356 84 REFERENCES 1. National Athletic Trainers Association. Athletic training services. Available at: http://nata.org/sites/default/files/GuideToAthleticTra iningServices.pdf. Accessed June 29, 2010. 2. Board of Certification. What is an athletic trainer? Available at: http://www.bocatc.org. Accessed on June 29, 2010. 3. Board of Certification. Defining athletic training. Available at: http://www.bocatc.org/athtrainer/DEFINE. Accessed September 13, 2010. 4. National Athletic Trainers Association. The facts about athletic trainers. Available at: http://nata.org/sites/default/files/AT_facts.pdf. Accessed December 7, 2010. 5. Mensch J, Crew C, Mitchell M. Competing perspectives during organizational socialization on the role of athletic trainers in high school settings. J Athl Train. 2005;40(4):333-340. 6. National Athletic Trainers Association. Official statement on athletic trainers in high schools. Available at: http://nata.org/sites/default/files/ATsInHSs/pdf. Accessed June 28, 2010. 7. National Athletic Trainers Association. Secondary school official statement. Available at: http://nata.org/sites/default/files/SecondarySchool.pd f. Accessed June 28, 2010. 8. Claiborne T, Hou S, Cappaert T. Certified athletic trainers provide effective care in the high school setting. Athletic Therapy Today. 2007;12(2):34-38. 85 9. American Medical Association. Athletic sports medicine. Available at: http://www.nata.org/sites/default/files/AMA_support.pd f. Accessed October 14, 2010. 10. National Athletic Trainers Association. Position proposal guide for certified athletic trainers in secondary school athletic programs. Available at: http://www.nata.org/sites/default/files/positionproposal-guide-for-certified-athletic-trainers-insecondary-school-athletics-programs.pdf. Accessed December 7, 2010 11. Nicols AW. The role of athletic trainers and physical therapists in sports medicine. Hawaii Med J. 1999;(58);81-82. 12. National Athletic Trainers Association. Consensus statement: Appropriate medical care for secondary school-aged athletes. Available at: http://nata.org/sites/default/files/AppropriateMedical Care4SecondarySchoolAgeAthletes.pdf. Accessed June 28th, 2010. 13. Casa DJ, Pagnotta KD, Pinkus DE, Mazerolla SM. Should coaches be in charge of care for medical emergencies in high school sport? Athletic Training Sports Health Care. 2009;1(4):144-146. 14. Knight CS, Badros KK, Medden CA, Drewer N, Makuchal P. Sports medicine and school nurses: A growing need for further education and appropriate resources. J School Health. 2006;76(1):8-11. 15. Lyznicki JM, Riggs JA, Champion HC. Certified athletic trainers in secondary schools: Report of the Council on Scientific Affairs. J Athl Train. 1999;34(3):272276. 16. Brunner M, Wagner RW, Lyles A, Biddington C. Athletic health care in Pennsylvania high schools. Pennsylvania 86 J Health, Physical Education, Recreation Dance. 2009;20-22. 17. Bell Ka, Prendergast HM, Schlichting A, Mackey E, Mackey, M. Preparedness among Illinois high school athletic departments: Does size or location matter? 2005;4(2):3-3. http://web.ebscohost.com. Accessed June 29, 2010. 18. Feder K, Frey C, Sleight J, Pendergraph B, Smallman D. Medical coverage of high school athletes in California. Athletic Training Sports Health Care. 2010;2:61-65. 19. Aukerman D, Aukerman MM, Browning D. Medical coverage of high school athletics in North Carolina. Southern Medical Journal. 2006;132-136. 20. Dillon, Naomi. Keeping student athletes safe. American School Board Journal. 2006;15-19. 21. Adirim TA, Cheng TL. Overview of injuries in the young athlete. Sports Med 2003;33(1):75-81. 22. Almquist J, McLeod TC, Cavanna A, et al. Summary statement: Appropriate medical care for the secondary school aged athlete. J Athl Train. 2008;43(4):416-427. 23. Nelson AJ, Collins CL, Yard EE, Fields SK, Comstock RD. Ankle injuries among United States high school sports athletes, 2005-2006. J Athl Train. 2007;42(3):381-387. 24. O’Donoghue EM, Onate JA, Van Lunen B, Peterson CL. Assessment of high school coaches’ knowledge of sports-related concussions. Athletic Training Sports Health Care. 2009;1(3):120-132. 25. Yard EE, Collins CL, Comstock RD. A comparison of high school sports injury surveillance data reporting by 87 certified athletic trainers and coaches. J Athl Train. 2009;44(6):645-652. 26. Massachusetts Department of Health. Physical activity. Available at: http://www.mass.gov/Eeohhs2/docs/dph/research_epi/heal thy2010-physical-activity.pdf. Accessed June 29, 2010. 27. National Federation of State High School Associations. High school sports participation increases for 20th consecutive year. Available at: http://www.nfhs.org/content.aspx?id=3505. Accessed October 14, 2010. 28. Morton, Michael. Local school districts say budgets limit hiring athletic trainers. MetroWest Daily News. Available at: http://www.metrowestdailynews.com/news/education/x1757 234224/llocal-school-districts-say-budgets-limithiring-athletic-trainers. Accessed September 30, 2010. 29. Almquist, J. Why do high schools need ATCS? Coach Athletic Director. 2001;8-9. 30. Berry J. Showing our value in dollars and cents. NATA News. June 1993;8-10. 31. Berry J. Research shows $$ value of atc. NATA News. March 1993;15. 32. Almquist J, Reynolds J. Secondary school settings support through cost analysis proceedings. National athletic trainers’ association 50th annual meeting and clinical symposia. Human Kinetics. 1999;121-123. 33. Massachusetts Department of Health. Access to health care. Available at: http://www.mass.gov/Eeohhs2/docs/dph/research_epi/heal thy201-access-healthcare.pdf. Accessed June 29th, 2010. 88 34. Health connector, health insurance for Massachusetts residents: health reform facts and figures fall 2010. Available at: https://www.mahealthconnector.org/portal/site/connecto r/menuitem.d7b34e88a23468a2dbef6f47d7468a0c?fiShown=de fault. Accessed October 26, 2010. 35. Bowman, Lee. Most high schools lack athletic trainers for their athletes. MetroWest Daily News. Available at: http://www.metrowestdailynews.com/new/x1757234220/most -high-schools-lack-athletic-trainers-for-theirathletes. Accessed September 30, 2010. 89 ABSTRACT TITLE: THE AVAILABILITY OF CERTIFIED ATHLETIC TRAINERS IN HIGH SCHOOLS IN MASSACHUSETTS RESEARCHER: Kathryn Annunziata, ATC ADVISOR: Dr. Carol Biddington PURPOSE: To determine the number of certified Athletic Trainers working at the secondary school level in Massachusetts. METHODS: Massachusetts high school athletic directors (N=44) were surveyed using www.surveymonkey.com. The survey consisted of 16 questions regarding certified Athletic Trainers and athletic health care availability to student-athletes in Massachusetts high schools. FINDINGS: Division I high schools were more likely to employ a certified Athletic Trainer than divisions II, III, or IV schools. High schools with more varsity boys’ and girls’ sports teams were more likely to have a certified Athletic Trainer than schools with less sports teams. Schools that indicated larger athletic budgets were more likely to have a certified Athletic Trainer than schools with less financial means. Also, the likelihood of certified Athletic Trainer employment significantly improved with more girls’ varsity sports. Finally, a majority (54.1%) of hired certified Athletic Trainers were part-time. CONCLUSION: After review of the results, it is concluded that 56.8% of high schools in Massachusetts have certified Athletic trainers available to their student-athletes. Schools of all sizes have begun to recognize the need for certified Athletic Trainers at the secondary school level. Many Athletic Directors (54.5%) at high schools in Massachusetts are satisfied with the athletic health care provided to their student-athletes.