Comparing NCAA Division II Athletes’ Perceptions of Social Support Following Injury, Illness, or Other Identified Life Stressors. A DISSERTATION 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 Doctor of Health Science (DHSc) in Health Science and Exercise Leadership By Martha Jane Anderson Research Advisor, Linda Meyer, EdD, LAT, ATC California, Pennsylvania 2021 CALIFORNIA UNIVERSITY OF PENNSYLVANIA CALIFORNIA, PA DISSERTATION APPROVAL Health Science and Exercise Leadership We Hereby Approve the Dissertation of Martha Jane Anderson Candidate for the Degree of Doctor of Health Science (DHSc) Date Faculty April 17, 2021 __________________________________________ Linda Meyer, Ed.D., LAT, ATC, Advisor April 21, 2021 April 21, 2021 __________________________________________ Ellen West, Ed.D., LAT, ATC April 21, 2021 __________________________________________ Tom West, Ph.D., LAT, ATC ACKNOWLEDGEMENTS I would like to thank my friends and family for their support through this process. Most of all, I would like to thank my committee members for all of their help, knowledge, and expertise. I could not have done this without you. A huge thank you to the Alvernia University Library, for allowing me to use your space to do my work. CONTENTS List of Figures……………………………………………………………………… ...... i List of Tables……………………………………………………………………………ii Abstract………………………………………………………………………………… iii Introduction……………………………………………………………………… ..........1 Methods………………………………………………………………………………....7 Research Design...................................................................................................7 Participants ...........................................................................................................9 Instruments ...........................................................................................................10 Demographic Survey ...............................................................................10 Perceived Stress Scale..............................................................................11 Multidimensional Scale of Perceived Social Support ..............................12 Athletic Multidimensional Scale of Perceived Social Support ................13 Procedures ............................................................................................................14 Data Analysis ...................................................................................................................16 Results ..................................................................................................................17 Demographics and Tabling of Statistics ..............................................................17 Hypothesis Testing...............................................................................................20 Additional Findings .............................................................................................24 Gender ..........................................................................................24 Year of Athletic Eligibility ..........................................................25 Discussion ........................................................................................................................28 Perceived Social Support .....................................................................................28 Comparisons of Providers of Social Support ......................................................32 Family ......................................................................................................33 Significant Others ....................................................................................33 Athletic Trainers, Teammates, Friends, and Coaches..............................34 Stress Buffering and Main Effects .......................................................................35 Integrated Model of Response to Sport Injury.....................................................36 Additional Findings .............................................................................................37 Gender ......................................................................................................38 Year of Athletic Eligibility ......................................................................40 Conclusion .......................................................................................................................42 Future Research ...............................................................................................................45 References ........................................................................................................................46 Appendices .......................................................................................................................63 Appendix A, Review of Literature...................................................................................63 Introduction ......................................................................................................................64 Stress ................................................................................................................................66 Injury as a Stressor ...............................................................................................67 Illness as a Stressor ..............................................................................................67 Other Identified Life Stressors .............................................................................68 Perception ........................................................................................................................70 Cognitive Appraisal .........................................................................................................72 Primary and Secondary Cognitive Appraisals .....................................................73 Personal Factors ...................................................................................................75 Athletic Identity .......................................................................................75 Mental Toughness ....................................................................................76 Hardiness..................................................................................................77 Additional Personal Factors .................................................................................78 Situational Factors ...............................................................................................79 Psychosocial Factors ............................................................................................80 Teammates ...............................................................................................82 Coaches ....................................................................................................84 Athletic Trainers ......................................................................................85 Friends......................................................................................................86 Family ......................................................................................................87 Significant Others ...................................................................................87 Social Support ..................................................................................................................89 Types of Social Support .......................................................................................91 Perceived Social Support .....................................................................................92 Stress Buffering Process ......................................................................................94 Main Effects Model .............................................................................................95 Self-Efficacy ........................................................................................................95 Theoretical Models ..........................................................................................................98 Comparison of Theoretical Models .....................................................................100 Integrated Model of Response to Sport Injury.....................................................101 Measurement Instruments ................................................................................................105 Multidimensional Scale of Perceived Social Support ..........................................106 Athletic Multidimensional Scale of Perceived Social Support ............................107 University Stress Scale ........................................................................................108 Perceived Stress Scale..........................................................................................108 Conclusion .......................................................................................................................110 Appendix B, Problem Statement......................................................................................112 Appendix C1, Collegiate Athletes’ Perceptions of Social Support Survey .....................115 Appendix C2, Additional Methods, Introductory Letter to Athletes ...............................128 Appendix C3, Athletic Director and Athletic Trainer Contact Information ....................130 Appendix C4, Email to Athletic Administrators..............................................................132 Appendix C5, Email to Designated Contact Athletic Trainers ........................................134 Appendix C6, Quick Response Code...............................................................................140 Appendix C7, Thank-you Email to Athletic Trainers ......................................................142 Appendix C8, IRB Review Request ................................................................................144 IRB Survey/Interview/Questionnaire Consent Checklist ....................................150 IRB Review Request Checklist ............................................................................152 IRB Director’s Certification ................................................................................154 IRB Approval Letter ............................................................................................155 Appendix C9, References ................................................................................................157 Appendix C10, Supporting Materials ..............................................................................185 Curriculum Vitae .................................................................................................186 C.I.T.I. Training Certificates................................................................................190 Copyright Permission...........................................................................................193 i List of Figures Figure 1. Conceptual Map of the Social Support Process................................................90 Figure 2. Integrated Model of Response to Sport Injury .................................................102 ii List of Tables Table 1. Classification of Injury Based on Time to Return to Activities ........................8 Table 2. Age and Sex of Participants ...............................................................................18 Table 3. Ethnicity of Participants.....................................................................................18 Table 4. Total Number and Percentages of Respondents Who Indicated Days of Activity Missed Due to Significant Injury, Illness and Stressors ......................19 Table 5. Means, Standard Deviations, and Scale Score and Level of Perceived Social Support ...............................................................................................................21 Table 6. Comparisons by Group for Perceived Social Support .......................................23 Table 7. Means and Standard Deviations for Gender and Level of Perceived Social Support ...............................................................................................................24 Table 8. Significance of Female Gender and Providers of Perceived Social Support…. 27 Table 9. Means, Standard Deviations, Mean Support Scale Score and Level of Perceived Social Support and Year of Athletic Eligibility .................................................26 Table 10. Effects of Year of Eligibility on Perceived Social Support .............................27 Table 11. Comparison of Theoretical Models .................................................................99 iii Abstract A social support network is something people need in difficult times. Athletes may have even more of a need for their social support network. The purpose of this research was to explore National Collegiate Athletic Association (NCAA) Division II athletes' perceived social support networks, which compared friends to teammates, family to coaches, and significant others to athletic trainers following injury, illness, or other identified life stressors. In this quantitative study, 546 participants completed a four-part survey that included a demographic section with the University Stress Scale, the Multidimensional Scale of Perceived Social Support, the Athletic Multidimensional Scale of Perceived Social Support, and the Perceived Stress Scale. Results indicated athletes perceived social support in the following hierarchical order from family, significant others, coaches, teammates, friends, and athletic trainers. There were significant differences across all groups when comparing the groups to one another for perceived social support. There were no significant differences in perceived support between friends, coaches, teammates, significant others, and family. All 546 participants reported feeling stress, with 352 stating moderate stress. Additional significant findings indicated that females compared to males preferred the support of friends, significant others, and athletic trainers; freshmen and sophomores perceived more social support from friends than did seniors. The results suggest differences exist when comparing perceived social support following injury, illness, or other identified life stressors. Keywords: Social Support, Multidimensional Scale of Perceived Social Support, Perceived Stress Scale, Athletic Multidimensional Scale of Perceived Social Support, Division II Athletes, Integrated Model of Response to Sport Injury 1 Comparing NCAA Division II Athletes’ Perceptions of Social Support Following Injury, Illness, or Other Identified Life Stressors. Stress, regardless of whether experienced due to an injury, illness, or other identified life stressor, can disrupt the collegiate athlete's quality of life. College sportsrelated injuries were estimated to be approximately six injuries per 1000 exposures out of a total of 176.7 million exposures to potential injury (practice and competition) from 2009 to 2014 (Kerr et al., 2015). The effects of acute or chronic illnesses and other identified life stressors on college athletes’ mental health have not received much attention in the literature. A majority of the previous research on emotional and social support focused more on elite and adolescent athletes (Arvinen-Barrow et al., 2014; Brewer et al., 2010; Evans et al., 2017; Roy et al., 2015). The NCAA (2019) stated in their Inter-Association Consensus Document, "Mental health is an important and often overlooked dimension of overall student-athlete health and optimal functioning. (p. 5).” Social support is one way to improve one's mental health (Acharya & Collins, 2018; Agbarov et al., 2012; Covassin et al., 2014; Petrie et al. ,2014; Sheridan et al., 2014). Lazarus (1990) noted the stress response occurs when the person's ability to appraise an event or situation cognitively exceeds their available resources to cope with the stressor. Saleh et al. (2017) suggested students’ stress "involves all aspects of life's difficulties, including psychological discomfort and each student deals with stress differently (p.1)." Collegiate athletes represent a unique population transitioning to adulthood, learning to live independently, and learning new coping skills (Gerlach, 2018). Athletes must navigate a new social environment, academic challenges, and an upward shift in the athletic talent with which they must compete. 2 According to Goodman et al. (2018), higher injury rates were reported for freshmen athletes than older, more experienced athletes. Also, "sharply increased workload presents a potential opportunity for fatigue in those who have not yet mentally and physically adjusted to the transition from high school to college sports (p. 364)." College athletes are more vulnerable to increased stress than non-athletes due to failing to identify social support networks and other resources which may help decrease their stress and reactions to those stressors (Bulo & Sanchez, 2014). Athletes are members of a team; therefore, they may be more socially welladjusted compared to non-athletes (Son et al., 2018) and possess improved social adjustment by belonging to a group or team which already has similarities established (Wilson & Pritchard, 2005). However, athletes who are injured, ill, or dealing with other identified life stressors may have difficulty coping socially, emotionally, and physically (Malinauskas & Malinasukiene, 2018). Injury, illness, or other identified life stressors represent an abrupt change to an athlete's familiar environment, and therefore a cognitive appraisal of their new circumstances must occur. The resulting emotional responses will be either positive or negative, resulting in positive or negative behaviors (Arvinen-Barrow et al., 2014; Podlog et al., 2015). At one-week post-injury, Albinson and Petrie (2003) found the more negative the secondary and emotional appraisal of injury, the more avoidance and coping behaviors were evident. Daly et al. (1995) reported those athletes who were injured had increased perceptions of stress and less ability to cope. One's athletic success may result from their ability to identify with, adjust to, and positively or negatively respond to this changing environment (Madrigal et al., 2017). 3 There can be many factors affecting cognitive appraisal. One of the personal factors affecting the cognitive appraisal of injury, illness, and stress may be gender (Acharya et al., 2018). Year of athletic eligibility and playing time may also affect cognitive appraisal (Bulo & Sanchez, 2014; Madrigal & Robbins, 2020). Other individual differences such as personality, coping skills, psychological skills, athletic identity, previous injury experience, or social support experience may also influence how an athlete responds to these stressors. (Weise-Bjornstal et al., 1998; Brewer, 2010) Roy et al. (2015) noted initial negative appraisal following an athletic injury. They stated this initial appraisal resulted from the influence of an athlete’s personal and situational factors and how these affect their psychological responses to injury or stress. Weiss and Troxell (1986) identified the potential for these responses to adversely affect the athlete’s rehabilitation outcomes, be more detrimental to return to participation, result in decreased motivation, and had the potential to worsen over the competitive season. Several authors have suggested that injured athletes will often turn to their support networks in times of distress which may include family and friends, teammates, coaches, and athletic trainers (Bennett et al., 2016; Malinasuskas & Malinauskiene, 2018; Mankad et al., 2009; Newman & Weiss, 2017). Social networks are a crucial component for health, well-being, and the learning and transfer of skills (Chiaburu et al., 2010; Umberson & Montez, 2010). Collegiate athletes are more likely to reach out to those they have the most in common such as teammates, coaches, and athletic trainers (Bianco & Elklund, 2001; DeFreese & Smith, 2014; Fletcher & Sarkar, 2012). Lakey (2010) noted that social support might include social integration, perceived support, and received support, and suggests, at times, the perceived support and received support may not 4 always be reciprocal. The theoretical model which best incorporates perceived, received, and reciprocal support, the influence of pre-existing factors, in addition to the timing of that support, is the Integrated Model of Response to Sport Injury, introduced by WieseBjornstal et al. (1998). The Integrated Model of Response to Sport Injury is a model explicitly used with an athletic population (Wiese-Bjornstal et al., 1998). The integrated model considers the influence of personality, previous experiences, coping behaviors, and prior interventions the athlete may have utilized before an injury and in their cognitive appraisal of a new injury or stressor. The proceeding emotional and behavioral responses (psychosocial responses) resulted from the ongoing cognitive appraisals that may have occurred throughout the injury, illness, and stress processes. As these theories and theoretical models were being developed and becoming more accepted for an athletic population, the need to measure social support in athletes also became apparent. Several instruments exist to measure social support's different aspects; included in this study are the Multidimensional Scale of Perceived Social Support, the University Stress Scale, and the Perceived Stress Scale. The Multidimensional Scale of Perceived Social Support (MSPSS) (Appendix C1) (Zimet et al., 1988) measures an individual's perception of the availability of social support from three distinct groups: friends, family, and significant others. Even though the MSPSS is not a test designed to apply to athletes, it has been used successfully in this population (Lu & Hsu, 2013; Malinauskas, 2010; Malinauskas & Maulinauskiene, 2018). A modified version of the MSPSS, the Athletic Multidimensional Scale of Perceived Social Support (AMSPSS) (Appendix C1), modified by the primary 5 investigator, measures the perceived support from teammates, coaches, and athletic trainers. These groups represent whom athletes will often turn to for support (Bennett et al. 2016; Malinauskas & Malinauskiene, 2018; Mankad et al. 2009; Newman & Weiss, 2017). The University Stress Scale (USS) (Appendix C1) was designed by Hurst (2008) and modified by Stillman and Hurst (2016), which measures specific stressors and their intensity in college students. For this study, the USS use will identify the single most significant stressor the college athlete has experienced in the past 12 months before completing the survey. Intensity will not be measured. A better way to determine the amount of stress one perceives to experience is through using the Perceived Stress Scale (PSS). The PSS-14 by Cohen et al. (1983) measures how much perceived stress is associated with different situations in an individual's life. The scale evaluates how unpredictable, uncontrollable, and overloaded individuals find their lives, ranging from low, medium, and high stress (Cohen et al., 1983). For this investigation, the PSS-10 (Cohen & Williamson, 1998) (Appendix C1) was used, with one modification by the researcher to assess the level of stress an athlete has experienced during the past 12 months versus the suggested time of one month. (Cohen et al., 1983; Cohen & Willamson, 1988). This adaptation to the scale was that athletes needed to recall their most significant injury in the past 12 months on the survey. The author felt the PSS modification would align better with the length of one year before completing the study. These measurement tools used together assess athletes' response to injury, illness, and 6 other identified life stressors and whom these athletes turn to for social support after experiencing the stressors. Therefore, the stated hypothesis driving this research is: there will be greater perceived social support from teammates compared to friends; coaches compared to family; and athletic trainers compared to significant others following injury, illness, or other identified life stressors. 7 Methods This study was a non-experimental group comparison research design. This section reviews the research design, subjects, instruments, procedures, and data analysis. Research Design A non-experimental research design is one in which there is no random assignment of subjects to any independent variables. In this study, the investigator looked for a correlational relationship between the independent and dependent variables without manipulating them. Independent variables were the college athletes' injury history (injury or no injury), illness history (illness or no illness), and perceived life stress history (low, moderate, or high). Injury, illness, or other identified life stressors had to occur in the previous 12 months. Dependent variables were the perceived social support from the six social support providers (friends, family, significant others, teammates, coaches, or athletic trainers). Injuries were categorized as described by Alles et al. (1979): minor or significant. Significant was further categorized as moderate, major, and severe (See Table 1). The classification of injury severity was the time it took to return to activity. The USS classified other identified life stressors (Stallman and Hurst 2016). 8 Table 1 Classification of Injuries Based on Time to Return to Activity Minor injury: Significant injury: Moderate: Major: Severe: return between 1 - 7 days return between 8-22 days return after 22 days disabling injury (amputation, quadriplegia, death) Adapted from: “The National Athletic Injury/Illness Reporting System 3-Year Findings of High School and College Football Injuries,” by W. F. Alles, J. W. Powell, W. Buckley, & E. E. Hunt Jr., 1979, Journal of Orthopaedic & Sports Physical Therapy, 1(2), p. 104. https://doi.org/10.2519/jospt.1979.1.2.103 The PSS indicated perceived stress levels (Cohen et al., 1983 and Cohen and Williamson, 1988. Othman et al. (2019) identified three levels of stress. A score of 0-13 indicated low stress, moderate stress was a score of 14-26, and high stress was a score of 27-40. Dependent variables were the athletes’ perception of social support from teammates, coaches, athletic trainers, friends, family, and significant others. This design's strengths were the accessibility to the population to be examined, the potential for a more significant number of subjects, and separating them by injury, illness, or other identified life stressors. There was no manipulation of the independent or dependent variables. The Multidimensional Scale of Perceived Social Support (MSPSS) and the Athletic Multidimensional Scale of Perceived Social Support (AMSPSS) surveys were brief, easy to administer, and easy to complete. With these instruments and their subscales, it was possible to identify the individual(s) whom athletes perceived as providing them with the most social support. Past studies suggest that MSPSS and PSS are reliable and valid (Denovan et al., 2019; Lee, 2013; Zimet et al., 1988; ErmisDemirtas et al., 2018). 9 Participants This study's participants represented a sample of convenience of male and female student-athletes, 18 years of age or older from 14 of the 18 universities, which comprise the Pennsylvania State Athletic Conference (PSAC). The universities who participated in this study were Bloomsburg, California University of Pennsylvania, Clarion, Edinboro, Indiana University of Pennsylvania, Kutztown, Lock Haven, Mansfield, Mercyhurst, Shepherd, Shippensburg, Slippery Rock, the University of Pittsburgh-Johnstown, and West Chester. As of 2018, the total number of student-athletes participating in sports in this conference was 7,978 athletes (US Department of Education, 2020). Respondents participated in those sports recognized as varsity sports at each institution within the PSAC. Bloomsburg, Clarion, Edinboro, and Lock Haven sponsor Division I Wrestling, and Lock Haven sponsors Division I Field Hockey. The majority of the athletes in the PSAC represented Division II sports, but there was participation from the Division I athletes. The athletes identified their division and sport in the survey's demographic section. Participants who were 18 years of age or older voluntarily participated in the study at each PSAC university (Appendix C2). Athletes had to be officially rostered student-athletes for the 2020-2021 school year and met all qualifying standards for athletic participation in the varsity sports sponsored by each university. The study included those athletes granted a medical hardship waiver or redshirt from their university or the NCAA. All athletes agreed to the informed consent (Appendix C2). A list of all NCAA-sponsored sports was comprised by reviewing each university's official 10 athletics website. The complete list of sports appeared on the demographic portion of the survey. Athletes who experienced an injury, illness, or stressor had to recollect and specify the length of time missed from lifting, conditioning, practice, or games. The participants' injuries were self-reported as no days missed; one week or less missed; eight to twenty-one days missed; or twenty-two or more days missed and did return to participation, and twenty-two or more days missed and did not return to participation. Other identified life stressors were self-reported on the PSS, which measured low, moderate, and high-stress levels. Athletes completed the MSPSS evaluating the perceived social support from friends, family, and significant others. The AMSPSS evaluated the perceived social support received from teammates, coaches, and athletic trainers. Instruments The survey was a four-part instrument designed using SurveyMonkey®, consisting of a demographic questionnaire, the PSS, MSPSS, and AMPSS. The USS, in the demographic section (Appendix C1), identified types of stressors, and the PSS (Appendix C1) measured levels of perceived stress, and the MSPSS and AMSPSS (Appendix C1) measured perceived social support. Athletes who did not complete the survey in its entirety were not included in data analysis, and their data was discarded. Demographic Survey. The demographic questions (Appendix C1) obtained background information on the athletes and their experience with injuries and other identified life stressors. Demographic questions included age, gender, ethnicity, year of athletic participation, primary sport, and had the athlete experienced an injury, illness, and stressors within the last 12 months. Also, participants indicated how many practices, 11 games, conditioning, or lifting days they missed due to injury, illness, and life stressors. Athletes also identified the single most significant life stressor from the past 12 months using the University Stress Scale (USS), which identified the most common of college student stressors (Stillman & Hurst, 2016) (Appendix C1). Finally, the athletes indicated whether they had returned to play during their competitive season. Perceived Stress Scale. The PSS measures the degree to which individuals appraise situations as stressful. Items evaluate how unpredictable, uncontrollable, and overloaded individuals find their lives. Scores were ranked as low, moderate, and high perceived stress (Cohen et al., 1983; Cohen & Williamson, 1988). Cohen et al. (1983) first introduced the stress scale that consisted of 14 questions. Cohen and Williamson (1988) later modified the scale to only consist of 10 questions and suggested the modified scale be used instead of the original 14 question scale. Many studies have identified the PSS as the most widely used scale to measure perceived stress (Denovan et al., 2019; Lee, 2013; Mills et al., 2017; Mozumder, 2017; Othman et al., 2019; Sun et al., 2019). The PSS is a widely used instrument; the scale has demonstrated that it also maintains its reliability and validity, even when modified in different languages. Sun et al. (2019) used the scale in Chinese and reported reliability as .95 and validity .81. Nordin and Nordin (2013) noted internal validity and reliability between .80 and .86, respectively, when used with Swedish participants. Mills et al. (2017) reported the reliability as .86 and .84 for perceived self-efficacy and perceived helplessness, respectively, when used with Lupus patients. Othman et al. (2019) stated three levels of perceived stress, based upon the scoring used by Cohen and Williamson (1988). Scoring the PSS, as suggested by Cohen 12 and Williamson (1988), is accomplished by the following: reversing responses (e.g., 0 = 4, 1 = 3, 2 = 2, 3 = 1 and 4 = 0) to the four positively stated items (items 4, 5, 7, & 8) and then summing across all scale items. Othman et al. (2019) noted low stress was indicated with a 0-13 score, moderate stress scored 14-26, and high stress scored 27-40. Multidimensional Scale of Perceived Social Support. The MSPSS (Zimet et al., 1988) (Appendix C1) measures the perceived social support received from friends, family, and significant others. There were 12 questions; four for each subscale of friends, family, and significant others, rated on a 7-point Likert scale ranging from very strongly disagree (scored with a 1) to very strongly agree (scored with a 7). Scoring for each subscale was achieved by adding the Likert scores for each subscale and dividing them by 4. The instrument's total score is factored in by adding all 12 questions' Likert scores and dividing them by 12. Zimet et al. (1988) stated that for both the subscale and total scale scores, low support indicated a mean score of 1 to 2.9; moderate support indicated a 3-5 total mean score, and high support indicated a total mean score of 5.1 to 7. Zimet et al. (1988) reported initial reliability for the three subscales of friends was .85; family was .87, and significant others were .91. The reliability for the entire scale scoring was .88. Test-retest reliability was .75 for friends, .85 for family, and .72 for significant others (Dahlem et al., 1991; Kazarian & McCabe, 1991; Zimet et al., 1988). Ermis-Demirtas et al. (2018) reported the internal consistency of the MSPSS with Cronbach's α to be .92. Internal consistency and reliability were calculated in this study and reported to be .93 for family support, .91 from friends, and .94 from a significant other. DeMaria et al. (2018) noted similar results for internal consistency of the MSPSS 13 when used with people with chronic diseases. Validity was also tested with confirmatory factor analysis and yielded significance from .79 or greater with a p < .001. Guan et al. (2015) also reported reliability ranging from .89 to .90 for the three subscales, and test-retest reliability was .71 with p < .01. In addition, validity was noted to be .82 to .92 with a p < .01. The MSPSS used friends, family, and significant others, and the AMSPSS used teammates, coaches, and athletic trainers. The MSPSS did not have any other changes or modifications. Athletic Multidimensional Scale of Perceived Social Support. There are no reliability and validity scores available for the AMSPSS (Appendix C1). The instrument's structure is identical to the MSPSS; however, the author modified social support providers to be teammates, coaches, and athletic trainers, versus friends, family, and significant others found on the MSPSS. In an email exchange with Dr. Zimet which he stated the reliability and validity should not change on the AMSPSS from the MSPSS. “This is due in part to the fact that the only items that are different between the two tests are the names of the providers of social support” (G. Zimet, personal communication, November 19, 2019). Scoring for the AMSPSS and the MSPSS was the same; 12 questions total, with four questions for each subscale of teammates, coaches, and athletic trainers, respectively. Questions used a 7-point Likert scale, ranging from very strongly disagree (score of 1) to very strongly agree (score of 7). Scoring for each subscale was achieved by adding the Likert scores for each subscale and dividing them by 4. The instrument's total score is factored in by adding all 12 questions' Likert scores and dividing them by 12. 14 Procedures Following California University of Pennsylvania’s IRB approval, contact was made via email and telephone to the administrators from each PSAC university for their interest in being included in the study. Athletic Administrators consisted of Athletic Directors, Directors of Intercollegiate Athletics, Senior Women's Administrators, Executive Director of Athletics, or Vice President of Athletics. These individuals will be identified as either AA or AAs from this point forward. The AAs were contacted via telephone (Appendix C3) if there were no responses to the email (Appendix C4). The AAs were informed of the study and given information regarding the study's purpose, study design, risks, and the informed consent statement (Appendix C4). AAs had the primary investigator's contact information, and AAs had to confirm their agreement for their university participating by sending an email back to the primary researcher. The AAs were asked to retain the researcher's information for future contact if they had any questions, concerns, or issues regarding participation in the study. Following AA approval, the primary researcher contacted each institution's designated contact athletic trainer via email and telephone (Appendix C5). The designated athletic trainer was either the head athletic trainer for their athletic department or was an athletic trainer with whom the primary investigator had a professional relationship. In this communication, the study's purpose, study design, methods, a copy of the instruments, and the consent statement were forwarded via email to the designated athletic trainer from each university for informative purposes only (Appendix C5). Included in the email were the QR code (Appendix C6) and hyperlink to the surveys so that the athletic trainers could distribute the information to the athletes on their respective 15 campuses. The designated athletic trainers distributed the instructions via email, text, or any other electronic team communication method each university employed to contact the athletes. All designated athletic trainers chose to contact their athletes via electronic means versus the flyers and posters. The designated athletic trainers' only responsibilities were distributing the introductory letter to the students with the hyperlink and QR code. The designated athletic trainer or staff member did not have any other involvement with data collection, data storage, or statistical analyses. After dispersing the electronic communication, all the student-athletes needed to scan was the QR code with their smartphone if they choose to participate. They also could access the SurveyMonkey® site’s hyperlink to the survey if they choose to take the survey on a computer or laptop/tablet device. After reading the QR code, the athletes were directed to the Survey Monkey® site, where they were to complete the survey. When using the hyperlink to access the survey, it referred them to the first page of the Survey Monkey® survey. Completion of the survey took on average ten minutes or less to complete. Data were stored on the Survey Monkey® website and were password protected by the primary researcher. An explanation of the study and a statement of implied consent was available before beginning the survey. Athletes completed the four-part survey. If participation in the study caused an increase in emotions or feelings, a list of free resources was available after the survey. There was a message on the final screen thanking the subjects for participating in the study. The designated athletic trainers received a thank-you email following the study's end (Appendix C7). 16 Data Analysis The main effects between the perceived level of social support from each support provider were dependent upon the severity of injury, illness, or other stressors measured using multifactorial analysis of variance (MANOVA). Examining the interactions between social support providers' perceived level of social support was done using posthoc testing. Factorial MANOVAS separately compared demographic differences of gender and year of athletic eligibility to the perceived social support subscales. Each of the six social support providers was examined for any interactions and correlations, utilizing a multifactorial MANOVA. Data analysis occurred using The Statistical Package for the Social Sciences (SPSS) statistical software with an α ≤ .05. MANOVAs compared the six subscales' means: friends to teammates, family to coaches, and significant others to athletic trainers. Also, MANOVAs were used to test for the main effects of injury status (injured or noninjured), illness, and other identified stressors. There is one hypothesis that drove this research study. There will be greater perceived social support from teammates compared to friends, coaches compared to family, and significant others compared to athletic trainers, following injury, illness, and other identified life stressors experienced by each participant. 17 Results The purpose of this research was to explore the individual social support following injury, illness, or other identified life stressors NCAA Division II athletes perceived from friends compared to teammates, family compared to coaches, and significant others compared to athletic trainers. This research also explored the effect of two independent variables on social support. The examined variables were gender and year of athletic eligibility. Assessment occurred with these two independent variables’ influence upon the six dependent variables of perceived social support from friends, family, significant person, teammates, coaches, and athletic trainers. This section includes demographics, hypothesis testing, tables of descriptive statistics, and additional findings. Demographics and Tables of Descriptive Statistics Approximately 4,325 male and female athletes from the PSAC received the survey via electronic means, and 654 responded. However, only 546 completed the survey in its entirety. The participants were NCAA Division II athletes who participated in NCAA sanctioned varsity male and female athletic teams on the campuses at 14 of 18 institutions within the PSAC. Participants had to be 18 years of age or older to complete the survey. The mean age and gender of the participants are in Table 2. 18 Table 2 Age (in years) and Gender of Participants Variable Minimum Maximum N M SD Male 170 19.3 1.21 18 25 Female 376 546 19.5 19.4 1.57 1.33 18 18 22 25 The participants represented all ethnic choices on the survey (Table 3). Eleven respondents chose not to answer the ethnicity question, and one respondent replied other. The majority of participants were white (84.2%), with 10.1% representing African Americans and 2.9% indicating Hispanic ethnicity. Table 3 Ethnicity of Participants White African American Hispanic Asian Alaskan Native Native Hawaiian No Answer Other n 460 55 16 1 1 1 11 1 546 % of Participants 84.2% 10.1% 2.9% 0.2% 0.2% 0.2% 2.0% 0.2% 100% Participants recalled any significant injury, illness, or other identified stressor they experienced in the past 12 months before completing the survey. The respondents indicated the number of days of participation they missed due to the significant injury, illness, or other identified stressor. Of the 546 athletes surveyed, 330, or 60.4%, stated 19 they experienced a significant injury (See Table 4). Respondents identified the body part which was injured. Injuries to the knee (21% of all injuries), ankle (18.7% of all injuries), and shoulder (13.6% of all injuries) were the most prevalent in those individuals who identified having an injury. Table 4 Total Number and Percentage of Respondents Who Indicated Days of Activity Missed Due to Injury, Illness, or Stressors No injury or illness Did not miss any days Missed less than a week Missed 1 to 3 weeks Missed Longer than 3 weeks, able to return the same competitive season Missed longer than 3 weeks, unable to return the remainder of the competitive season Severe injury resulting in permanent disability (Loss of limb, quadriplegia, death) Other Injury Incident 148 11 Percent of total participants 28% 2% Illness Incident 148 3 Percent of total participants 28% 1% Stressor Incident N/A 10 Percent of total participants N/A 2% 71 65 13% 12% 25 33 2% 6% 408 75 75% 14% 76 14% 3 1% 23 4% 107 20% 4 1% 30 5% 0 68 546 0% 11% 100% 0 330 546 0% 61% 100% N/A N/A 546 N/A N/A 100% 20 Those athletes who experienced a significant illness comprised 11% (n=68) of the total respondents, with the other 89% (n=478) of the respondents stating no illness in the past 12 months. Of those athletes who noted a significant illness, 51% (n=28) said they missed less than a week of participation, 34% (n=33) missed one to three weeks of participation but were able to return to competition. In comparison, 6% (n=4) could not return to competition (See Table 4). All of the 546 participants reported experiencing stress (See Table 4). Seventyfive percent (n=418) stated they missed at least one day of participation but less than a week due to the impact of that stressor (See Table 4). The USS (Stallman, 2008; Stallman & Hurst, 2016) was used to identify the respondents' specific stressors. Of the total participants, the two most significant life stressors experienced were academics and coursework (25% or 137 of all respondents) and mental health issues (20% or 109 of all respondents). The PSS (Cohen et al., 1983) identified perceived stress levels. Twentyeight percent of respondents indicated low levels of stress (n=153) of respondents, 64% indicated moderate levels of stress (n=352), and the remaining 8% (n=38) indicated high levels of stress. Hypothesis Testing The hypothesis tested in this research study is the following. H1: There will be greater amounts of perceived social support from teammates compared to friends, coaches compared to family, and athletic trainers compared to significant others (α=p< .05 was considered statistically significant). 21 To test the hypothesis, a repeated measures MANOVA was performed to evaluate if a significant difference existed between the six dependent variables evaluating each source of perceived social support using the MSPSS (Zimet et al., 1988) and the AMSPSS. The seven-point Likert scores ranged from very strongly disagree (1 point) to very strongly agree (7 points). The possible score of perceived social support from each provider of social support ranged from 7-28. Mean perceived social support scores are in Table 5. Also in table 5 are the Scale Scores. A low scale score of perceived support was from 1-2.9, moderate support was from 3-5, and high support was from 5.1 to 7 (Zimet et al., 1988). Table 5 Means, Standard Deviations, Scale Score, and Level of Perceived Social Support Provider of Social Support Family Friends Significant Other Teammates Coaches Athletic Trainers M SD Scale Score 23.14 20.92 23.09 21.22 21.53 20.18 4.92 4.73 5.26 5.23 5.32 5.34 5.78 5.23 5.77 5.30 5.38 5.04 Level of Support High High High High High Moderate A repeated measures MANOVA was calculated to evaluate if a significant difference existed between the six dependent variables evaluating the source of social support. A significant difference was found between the 6 groups (F(4.177,2277) = 54.55, p = < .001). Differences between groups utilized follow-up post-hoc testing by running paired t-tests. As there are 15 paired samples, the significance level needed to be 22 corrected top < .00333. Paired sample t-tests demonstrated several significant differences between support groups. Friends, teammates, and coaches indicated a significant difference to family, significant others, and athletic trainers. Family had a significant difference compared to friends, coaches, and athletic trainers. Significant others showed a significant difference to friends, teammates, coaches, and athletic trainers. Athletic trainers had significant differences when compared to all other support groups. These results suggest significant differences in perceived support based on support providers. The comparisons of perceived social support and providers of social support and level of significance are in Table 6. 23 Table 6 Comparisons by Group for Perceived Social Support Social Support Group Comparisons Significant Other/ Friend Significant Other/Athletic Trainer Significant Other/Teammates Significant Other/Coaches Family/ Friends Family/ Athletic Trainer Family/ Teammates Family/ Coach Athletic Trainer/ Teammates Athletic Trainer/ Coaches Friends/ Athletic Trainer Friends/ Coaches Friends/ Teammates Significant Other/ Family Teammates/ Coaches Note. *statistically significant at p < .00333 Mean Difference 2.17 2.91 1.87 1.56 2.21 2.96 1.92 1.61 -1.04 -1.35 0.75 -6.04 -0.30 -0.05 -0.31 SD t df p 4.870 6.380 5.990 5.975 4.648 5.927 5.458 5.382 4.901 5.343 5.553 5.562 4.682 4.695 4.579 10.386 10.673 7.295 6.103 11.113 11.668 8.201 6.974 4.977 5.920 3.152 2.539 1.471 0.228 1.580 545 545 545 545 545 545 545 545 545 545 545 545 545 545 545 <.001* <.001* <.001* <.001* <.001* <.001* <.001* <.001* <.001* <.001* .002* 0.011 0.142 0.820 0.115 24 Additional Findings Gender A repeated measures MANOVA was calculated to compare the effect of gender on the six providers of perceived social support. The means and standard deviations for gender and social support can are in Table 7. A significant effect was found (λ (6,538 = .974, p = .028). Tukey HSD post hoc testing indicated that gender significantly affected perceived social support from friends, significant others, and athletic trainers (See Table 8). Women perceived greater social support than men from friends, significant others, and athletic trainers. Table 7 Means and Standard Deviations for Gender and Level of Perceived Social Support Provider of Support Friends Male/Female Male Female* Family Male Female Significant Other Male Female* Teammates Male Female Coaches Male Female Athletic Trainer Male Female* Note. * indicates significance. M SD n Mean Scale Score 20.31 21.20 23.04 23.19 22.20 23.49 20.73 21.44 21.34 21.61 19.46 20.51 5.110 4.541 4.951 4.912 5.708 5.010 4.968 5.342 4.938 5.488 5.222 5.367 169 376 169 376 169 376 169 376 169 376 169 376 5.07 5.30 5.76 5.79 5.55 5.87 5.18 5.36 5.33 5.40 4.86 5.12 Level of Social Support Moderate High High High High High High High High High Moderate High 25 Table 8 Significance of Female Gender and Providers of Perceived Social Support Provider of Support Friends Significant Other Athletic Trainer Teammates Coaches Family Type III SS 92.723 196.062 127.027 57.967 8.573 2.534 df 1 1 1 1 1 1 MS 92.723 196.062 127.027 57.967 8.573 2.534 F 4.154 7.151 4.484 2.120 0.303 0.104 p 0.042* 0.008* 0.035* 1.460 0.583 0.747 Note. *indicates statistically significant p < .05 Year of Eligibility A repeated measures MANOVA was calculated examining the effect of year of eligibility on perceived social support providers. Table 9 displays the means and standard deviations of perceived social support by year of eligibility: Freshmen, Sophomore, Junior, Senior, and 5th-year Senior. A significant effect was found (λ (24,1871.091 = .930, p = .025). Significance testing indicated that year of eligibility had a significant effect on friends' and coaches' perceived social support (see Table 10). A post hoc Tukey HSD revealed no significance for years of eligibility with coaches as perceived social support providers. Freshmen and sophomores perceived more social support from friends than compared to seniors. 26 Table 9 Means, Standard Deviations, Mean Support Scale Scores, Level of Perceived Social Support, and Year of Athletic Eligibility Provider of Support Year of Eligibility M Freshman@ 21.33 Sophomore $ 21.28 Junior 20.88 Seniors @$ 19.22 5th Yr Senior 20.96 Family Freshman 23.55 Sophomore 23.58 Junior 22.74 Senior 22.04 5th Yr Senior 22.20 Significant Other Freshman 23.70 Sophomore 22.86 Junior 22.95 Senior 22.09 5th Yr Senior 22.80 Teammates Freshman 21.63 Sophomore 21.13 Junior 21.52 Senior 20.05 5th Yr Senior 20.64 Coaches Freshman 22.30 Sophomore 21.55 Junior 20.79 Senior 20.43 5th Yr Senior 21.20 Athletic Trainer Freshman 19.89 Sophomore 20.25 Junior 20.67 Senior 19.79 5th Yr Senior 21.40 Note. *@$ Indicates Significance p < .05 Friends SD 4.533 4.583 4.504 5.44 5.029 4.608 4.538 5.122 5.909 4.924 4.941 5.217 5.219 6.160 5.261 4.465 5.467 5.396 6.224 5.765 4.475 5.883 5.368 6.089 5.331 4.963 5.750 5.316 5.558 5.575 n 211 134 100 76 25 211 134 100 76 25 211 134 100 76 25 211 134 100 76 25 211 134 100 76 25 211 134 100 76 25 Mean Support Scale Score 5.33 5.32 5.22 4.80 5.24 5.88 5.89 5.68 5.51 5.55 5.92 5.71 5.73 5.52 5.70 5.40 5.28 5.38 5.01 5.15 5.57 5.38 5.19 5.10 5.30 4.97 5.06 5.16 4.94 5.35 p Level of Support .008* .020* .935 .020* .496 1.000 1.000 .658 .148 .693 .599 .599 .768 .152 .928 .910 .910 1.000 .162 .900 .705 .705 .131 .065 .863 .975 .975 .751 1.00 .669 High High High Moderate High High High High High High High High High High High High High High Moderate High High High High High High Moderate Moderate High Moderate High 27 Table 10 Effect of Year of Eligibility on Perceived Social Support Provider of Support Type III SS Friends 271.500 Coaches 273.446 Family 190.930 Significant Other 164.604 Teammates 156.852 Athletic Trainer 91.013 Note. *indicates significance p < .05. df 4 4 4 4 4 4 MS 67.89 68.36 47.73 41.15 39.21 22.75 F 3.075 2.445 1.987 1.492 1.438 0.798 p 0.016* 0.046* 0.095 0.203 0.220 0.527 28 Discussion The challenge in supporting current collegiate athletes is assisting them as they navigate being on their own, face new academic challenges, be competitive collegiate athletes, and oversee their physical and mental well-being. For these reasons, many different individuals provide social support for collegiate athletes. Current research identifies teammates, coaches, and athletic trainers as a strong support network (Bejar et al., 2019; Clement et al., 2015; DeGroot et al., 2018; Bennett et al., 2016; Newman & Weiss, 2017). Others recognize that friends and family support these athletes (Agbarov et al., 2012; Lu & Hsu, 2013; Malinauskas, 2010; Malinauskas & Malinaskeine, 2018). The current study identifies those individuals whom athletes perceive as providing them with the most significant social support. The results provide more insight into whom athletes may seek out for social support and how they perceive the level of that support following injury, illness, or other identified life stressors. Perceived Social Support When comparing the mean scores on the MSPSS and AMSPSS, athletes reported perceiving greater social support from family, significant others, teammates, coaches, friends, and athletic trainers, respectively. These results would appear to support the hypothesis partially. The median teammates' scores were 21.22 compared to 20.92 to that of friends’, supporting the hypothesis. However, the median family support score was 23.14 compared to the coaches' scores of 21.53. The median score for significant others was 23.09 compared to the athletic trainers' scores of 20.18, neither of which supports the hypothesis (Table 5). Only athletic trainers scored as providing moderate levels of perceived social support, compared to all other groups who provided high social support 29 levels. When comparing the means and standard deviations of the instruments' scores, it is evident the scale scores are closely related for all groups and fall between a rating of 5 to 7 (agree to very strongly agree) for each of the four questions relating to the specific provider of support. What appears to be a statistically significant difference in scores on the MSPSS and AMSPSS, in reality, the scores are very similar to one another. The expectations of this study were that teammates would provide more social support compared to friends, coaches compared to family, and athletic trainers compared to significant others. Several of the group comparisons were of significance. (Table 6). Significant others compared to athletic trainers were statistically significant, as were family compared to coach. The comparison which showed no significant differences was friends compared to teammates. None of these results support the hypothesis, but they offer some insight into whom athletes perceive to receive social support. At first glance, these results may seem to be surprising since teammates, coaches, and athletic trainers might be more than likely providing the college athlete more inperson contact and support than compared to family, friends, and significant others (DeGroot et al., 2018; Bejar et al., 2019). Looking more closely at the results, it is evident that although the results were significant for varying levels of perceived social support from the support providers, the scores from the MSPSS and AMSPSS are still very close in proximity. What is of concern is that athletic trainers' scores indicated only providing moderate support levels compared to all other groups who provided high levels of perceived social support. Sixty-one percent of athletes noted injury as their most significant stressor, compared to 11% citing illness and 28% reporting no injury or illness. However, all 30 participants reported experiencing some degree of stress. Sixty-four percent noted moderate levels of stress. Athletic trainers are mentioned in the literature as important social support providers (Bejar et al., 2019; Bennett et al., 2016; Clement and Shannon, 2011; DeGroot et al., 2018; Newman & Weiss, 2017). DeGroot et al. (2018) stated that the athletic trainer is thought to be the most important support system for the injured athlete because of their constant interaction throughout rehabilitation. With two-thirds of the athletes noting an injury, one would expect the athletic trainer would be more involved in the treatment of those participants and be ranked higher in providing social support than they were compared to the other providers. Additionally, all athletes noted some stress level; surprisingly, the athletic trainer was not more involved in assisting those athletes in dealing with their stress if athletic trainers are as crucial to the stressed athlete as they are to the injured athlete. Compared to current literature, these individual scores for providing social support contradict studies where the athletic trainer was identified as providing more support than coaches or teammates. Comparing the scores on the AMSPSS/MSPSS, they show more support from parents or friends compared to coaches or athletic trainers, which agrees with the literature, as noted by Agbarov et al. (2012); Covassin et al. (2014); and Sullivan et al. (2020). As was suggested by Gabana et al. (2017), if athletes have positive relationships with those who provide social support, they are more likely to retrieve those positive memories and overcome future hardships. Judging from the results of the MSPSS and AMSPSS, it is possible that all of the athletes had already established some degree of positive relationships or had a more positive emotional climate with all of those who 31 provided them with social support. However, some of those relationships ranked higher depending upon each individual's level of positive interactions with those individuals who provided support to them at one point or another (Mankad et al., 2009). In this study, the result was that athletic trainers were ranked the lowest, but again it does not imply that they were providing less impactful levels of social support. It is also possible that because these are collegiate athletes, they have already attained some level of emotional intelligence when it comes to dealing with an injury, illness, or other life stressors. This increased emotional awareness can also attribute to higher scores on the MSPSS and AMSPSS. Increased perceptions of social support could be the result of athletes who also had increased levels of emotional intelligence and emotional climate, which would, in turn, may also lead to improved emotional well-being (Bolling et al., 2019; Gayles & Baker, 2015; Madrigal & Robbins, 2020; Malinauskas & Malinasukiene, 2018). Improved emotional well-being is the whole purpose of social support. From the results of the MSPSS and the AMSPSS, one cannot understand what type of social support athletic trainers are providing compared to the other groups. Is it possible athletic trainers provide more informational and task challenge support (Bennett, 2016; Robbins & Rosenfeld, 2001; Surya et al., 2015; Unruh 2005) and friends, teammates, coaches, significant others, and family provide more emotional and tangible support (Poucher et al., 2018; Wayamount & Huffman, 2020), and the athlete perceives this to be more important? However, these scores may imply that this study did not examine the type of support perceived by athletes, so it is not easy to make those assumptions based on the study's data. 32 Another question would be, do athletic trainers need to be more reflective and aware of the type of support they provide for all athletes, not just those injured or ill? According to the NCAA, mental health and well-being are the responsibility of all university members' athletic support networks (NCAA, 2016; NCAA, 2019). Hagiwara et al. (2017) stated that social support occurs between individuals who have had, on some level, an interpersonal relationship, and the social support was an interactive, positive experience between these individuals. It appears that athletic trainers may need to provide slightly more support than they are currently giving or improve the support and emotional environment they are making available to the athletes, especially compared to the other five groups involved in this study. Again, the scores were so closely aligned, and the instruments are not identifying athletic trainers as not providing any social support. Perceived social support from athletic trainers did score the lowest on the AMSPSS, compared to the other groups on the MSPSS and AMSPSS. Comparisons of Providers of Social Support Eleven of the fifteen comparisons were statistically significant, based upon their p values being less than the set α level of .05. None of these comparisons supported the hypothesis that teammates, coaches, and athletic trainers would provide more social support when compared to friends, family, and significant others. The four comparisons which had no statistical significance were perceived social support from friends compared to coaches; friends compared to teammates; significant others compared to family, and teammates compared to coaches (See Table 6). The lack of significance 33 would indicate that friends and teammates may provide similar social support levels, but one is not greater than the other. Family Perceived social support from family scored the highest compared to friends and significant others on the MSPSS, coaches, teammates, and athletic trainers on the AMSPSS; however, these results were not significant. One of the reasons for this highest score could be that the family provided the most basic social support, as they may only be getting the athlete's perspective of the situation. The social support athletes are likely to receive would be listening and emotional social support (Poucher, 2018; Wyamount & Huffmanm, 2020). While friends or teammates could also provide this type of support, it seems to apply to the family the best. This result fits because the family and the athlete will have the longest relationship. The athlete can receive more individualized support, and it is more than likely what the athlete is seeking initially in terms of social support. They need someone to listen to their problems and support them, someone who is readily available and can be communicated with in-person, over the phone, through video, or other technologies. Significant Others The perceived social support from significant others scored higher than friends on the MSPSS and athletic trainers, teammates, and coaches on the AMSPSS. Freeman (2020) identified a significant other as an individual who has expertise and similarity to the individual receiving the support. Using this definition, a more robust relationship than merely friends or teammates is suggested. The significant others share many more things in common and, in confidence, can give the athlete another perspective when 34 understanding the social support received and how it relates to their return to activity (Agbarov et al., 2012; Fletcher & Sarkar, 2012; Mitchell et al., 2014). Social support from a significant other may also be more meaningful to the athlete when compared to the other providers of social support. This more meaningful support may result from the significant other and athlete having a deeper interpersonal relationship, as Hagiwara et al. (2017) suggested. Also, the type of social support provided can make a difference. By using Pines et al.'s (1981) definition of reality confirmation where the support provider has values similar to their own, in that case, the significant other could also confirm the athlete's perceptions of the social support (Richman et al., 1993). In Pines et al.'s (1981) definition of task challenge support, a significant other may also challenge the athletes' perception of the task or activity to provide motivation and positively respond to social support. Athletic trainers, teammates, friends, and coaches may provide task challenge support and reality confirmation, but significant others may be more likely to provide emotional and tangible assistance. Athletic Trainers, Teammates, Friends, and Coaches Athletic trainers, teammates, friends, and coaches are in a unique position. They may spend a significant amount of time with the athlete, especially following injury or illness, or even other stressors, thereby providing different support types and support levels as they progress back into activity. These additional support types and levels may also explain why athletic trainers scored so closely with teammates, friends, and coaches on the MSPSS and the AMSPSS. These were the groups with whom the athlete would have had the most physical and social contact (Bennett et al., 2016; Robbins & Rosenfeld, 2001). 35 Perhaps what differentiates these social support providers from one another is whom the athlete feels more comfortable reaching out to for support. It is also possible that the athlete may realize they might receive and benefit from any one of the eight types of support from these different individuals at any given point in time (Pines et al., 1981; Richman et al., 1993). This support would need to occur following any combination of injury, illness, or other identified stressors. The person or persons providing the support must give positive messages in the support they are offering to the athlete. Stress Buffering and Main Effects The athletes in this study identified their most significant injury, illness, or other identified life stressor in the past 12 months before taking the survey. An athlete could have encountered all three of these circumstances and acknowledged them on the survey. Of particular note, all of the 546 participants indicated some stress level in the 12 months before completing the survey, with 64% (n = 352) experiencing moderate stress. Also, 61% (n = 330) noted an injury in the year before completing the survey, and 11% (n=68) cited an illness. At any one point in time, the perceived social support could provide one or both of the stress-buffering effect or main effects component of social support. The eight types of social support can act as the stress-buffering or palliative pathway in protecting the individual from the adverse psychological and physiological responses to stress (Cohen & Wills, 1985; Hornstein & Eiesenberger, 2016; Lakey et al., 2015; Mitchell et al., 2014). The stress buffer acts as a safeguard to the athletes from negative responses. However, social support can also act as the main effect or preventative pathway. 36 The social support received would have had a positive impact regardless of the level of stress the athlete may be experiencing (Bianco & Eklund, 2001; Cohen et al., 2000; Hartley and Coffee, 2019). Both physiological and psychological responses to perceived social support ideally would result in the decreased response to the stressor and the athlete's ability to better cope with the stressors, therefore, preventing the stressor's negative impact on the individual (Mitchell et al., 2014). It is also important to remember that the athlete may not experience all social support as positive. While the provider of support's intention may be to provide positive support, the athlete may perceive it as more negative and not helpful to their return to sport. The support perceived from individuals tends to occur in a cyclical pattern throughout experiencing the stressor and their return to activity so that support can differ throughout this cycle. Integrated Model of Response to Sport Injury These cyclical patterns of experiencing and responding to a stressor (injury, illness, or other identified life stressor) are the foundation of the Wiese-Bjornstal et al. (1998) Integrated Model of Response to Sport Injury. This model recognizes the importance of personal and situational factors before and after responding to a stressor. After experiencing these personal and situational factors, the individual will produce cognitive, emotional, and behavioral responses to sport injury, illness, or other identified life stressors (Wiese-Bjornstal et al., 1998). Wiese-Bjornstal et al. (1998) stated, "The core of the integrated model posits that cognitions, such as self-perceptions, are important because they, in turn, influence the emotional and behavioral responses of athletes to injury (p. 50)." The athletes most likely would have demonstrated a need for assistance in their responses to these stressors, whether it was a positive or negative response. 37 Based on the responses to this study, it was clear that athletes experiencing stressors sought to receive some social support from various individuals throughout the reaction to the stressor. Although the scores were similar and there was significance between groups in the scoring of the MSPSS and the AMSPSS, there was no one group of individuals which scored exceptionally higher when compared to the other groups. It was more than likely that the athletes were all in different coping stages with their stressors when they completed the study. Some may have had to recall how they felt after an injury, illness, or other stressor and the support they received, while others may have been experiencing their response to stressors when they took the survey. There was no differentiation between these differences in this study. Some participants (61%, n = 330) in the survey recalled an injury, while others identified their stressors as academic and course work (25% of total respondents). Others identified mental health issues (20% of total respondents) as their most significant stressor, as determined on the USS in the survey's demographic portion. Also, procrastination and life/study balance were each ranked as significant by approximately 9% of the respondents, respectively. Regardless of the stressor, it was evident that all the participants in this study needed to cognitively appraise where they were mentally, identify their emotional response, and rate how they perceived the social support from the groups identified. Based on the responses and results of the MSPSS and the AMSPSS, it seems all of the providers of social support provided some level of positive support. Additional Findings This study also examined the effects of gender and year of athletic eligibility on perceived social support. The hypothesis is that there would be gender differences when 38 athletes rated perceived social support from the six providers of social support examined in this study. An additional hypothesis was that there would be differences in perceived social support based on the year of athletic eligibility. Gender. In this study, females perceived more significant social support than males when friends, significant others, and athletic trainers provided the social support (See Table 8). This finding could result from the higher percentage of cisgender women (69%) than cisgender men (31%) completing the survey. Unruh et al. (2005) reported that more high-profile sports reported more satisfaction with their athletic trainer when compared to lower-profile sports. This satisfaction was especially true for female athletes when compared to males. Cooper et al. 2017 noted higher rates of stressors for those higher-profile sports when compared to the lower-profile sports. It is possible in this study that females represented more high-profile sports and possibly experienced more stressors than their male counterparts, thus perceiving more social support from their athletic trainer, significant other, and friends. In this study, there was more representation from females in the high-profile sports: Women's Soccer (9.7% of respondents) compared to Men's Soccer (3.4% of respondents), Softball (9.9% of respondents) compared to Baseball (6.6% of respondents), and Football (9.9% of respondents) represented high-profile sports, followed by Women's Track (5.3% of respondents) compared to Men’s Track (2.1% of respondents) and Women’s Basketball (5.4% of respondents) compared to Men’s Basketball (1.8% of respondents). The current study did not compare types of injuries but did compare females to males when it came to perceived social support. In terms of gender, Kontos et al. (2013) examined gender differences in concussion compared to orthopedic injuries. They found 39 that females tended to appraise their injury more negatively when compared to males, thus needing more social support than the men. This appraisal resulted from males reporting more pressure to return to their sport than females. There is the suggestion that males should portray a more masculine sport culture, such as that which occurs in recognizing pain (Christopher et al., 2020), in showing a more masculine athletic identity (Watson, 2016), and possessing mental toughness (Madrigal et al., 2015), and hardiness (Salim et al. (2016). Li et al. (2017) found that males who reported depression and anxiety were more likely to suffer an injury and needed more support in their study of male and female athletes. There were 170 male athletes in the present study compared to 376 female athletes. It is possible that because the comparison of male to female athletes was disproportionate, that females would have automatically reported higher levels of perceived social support from all providers of social support. The mean numbers were significantly different when comparing females' to males' social support from friends, significant others, and athletic trainers. Suppose cisgender females were more satisfied with their athletic trainer's social support. In that case, it could indicate that females tend to seek more social support than cisgender males, especially when it comes to stress from an athletic injury (Madrigal & Robbins, 2020). Because of the pressure to maintain an athletic identity of strength and hardiness, males may under-report the need for social support from friends, significant others, and athletic trainers. Therefore, social support should be available to both males and females equally, understanding that males may need more social support than they seek, especially from friends, significant others, and athletic trainers. 40 Year of Athletic Eligibility. In this study, freshmen and sophomores reported more social support from friends compared to seniors. When comparing freshmen, sophomore, juniors, and senior athletes and their social support needs, there can be many different personal characteristics to consider. First-year students and sophomores are more likely to have less emotional intelligence (Goodwin et al., 2018), lack mental toughness (Madrigal, 2015) and hardiness (Salim et al., 2016) in competing at the college level, and have yet to establish their own athletic identity (Watson, 2016). They may be less likely to cope with emotional trauma based upon their social support network structure. Lan and Xuebing (2018) reported first-year students and sophomores had more concern about their health when compared to juniors and seniors in college. Wu et al. (2018) also said first-year students and sophomores had lower positive mental health when compared to juniors and seniors. Freshmen may be more likely to turn to their friends or family for support than their teammates or coaches. The support that friends offer may differ from teammates because interpersonal relationships between the team's older members and the coaching staff have yet to materialize. Freshmen and sophomores have a stronger bond with their friends. They have maintained characteristic similarities (Mitchell et al., 2014) and are more than likely to have had similar life experiences until this point in their athletic careers (Christino et al., 2015; Lan & Xuebing, 2018). Malinauskas and Malianuskiene (2018) reported similar findings. This stronger bond would result in more beneficial social support from their friends when compared to teammates, coaches and athletic trainers, significant others, and even family. Therefore, it is not surprising that freshmen 41 and sophomores perceived more social support from their friends than other support providers. However, there were many more freshmen and sophomores in this study than juniors and seniors. There were 211 freshmen and 134 sophomores compared to 100 juniors and 76 seniors (See Table 9). Had the numbers of freshmen and sophomores been more comparable to juniors and seniors, the results may not have been as significant. Madrigal and Robbins (2020) did not report any differences between the year of athletic eligibility when identifying stressors. Juniors may not have been relying as much on their social support networks because they had already established their athletic identity, mental toughness, hardiness, and ability to cope with more adversity than compared to freshmen and sophomores (Christino et al., 2015; Hardy et al., 1991). 42 Conclusion Sustaining injuries, experiencing an illness, or dealing with other identified life stressors can occur at any point in time with athletes of all ages, but even more so with collegiate athletes. Collegiate athletes have high demands placed on them with academic pressures and athletic performance pressures. Any disturbance to this delicate balancing act can have detrimental effects physically and psychologically if not dealt with promptly. It is clear from the current research and the present study that athletes seek out social support from various people (Bennett et al., 2016; Malinauskas & Malinauskeine, 2018; DeFreese & Smith, 2014; Fletcher & Sarkar, 2017). The statements made by the NCAA support this research (NCAA, 2014; NCAA, 2019; NCAA, 2020). In this study, athletes noted perceiving high social support from all groups, except for athletic trainers, who were rated as only provided moderate support. However, males rated both friends and athletic trainers as only providing moderate support when compared to females. Athletic trainers may need to improve their ability to understand the individual athlete's cognitive appraisal of their stressors and adjust their support accordingly and consider the sex of the athlete. Without a qualitative component, it is not easy to understand why athletic trainers scored as only providing moderate social support. Athletes' appraisals of their situation are individualized. Those athletes dealing with an injury may have different needs than an athlete dealing with an illness or other identified life stressor, and vice versa. What is essential to understand is the athletes have demonstrated a need for social support from all individuals. Providers of social support need to be prepared to recognize this need, meet those needs, and provide adequate 43 support to these athletes. In this study, 64% of the respondents indicated experiencing moderate levels of stress, and 7% noted high levels of stress, and only 28% noted low levels of stress. These stress levels demonstrate the need for social support, even in the absence of injury or illness. Clinicians especially need to challenge the athletes and be aware of the athletes' cognitive appraisals at the interactions' time. According to the Integrated Response to Sport Injury Model (Wiese-Bjornstal et al., 1998), these appraisals will constantly be changing, so providers of social support need to adjust their types of support accordingly. With positive social support, athletes may be better prepared to deal with adversity without having detrimental effects on their academic and athletic performances. Of utmost importance is providing support for their mental health as the athlete progresses from the onset of injury, illness, or other identified life stressors throughout their response to those stressors and how they cope and return to activity. Gender and year in school are also considerations when identifying those that need social support. Most studies agree that women seek out more support when compared to men. However, disproportionate ratios of males to females in these studies may skew this information. Men and women will seek out different support types based on their athletic identity and possibly even their sport. Freshmen and Sophomores demonstrated receiving more support from friends when compared to juniors and seniors, which decreased as the year of eligibility increased. This support could result from more significant numbers of freshmen and sophomores than juniors and seniors in this study. There is a need to identify freshmen and sophomores' needs compared to juniors and 44 seniors. By identifying their needs, social support's type and frequency can be better suited to meet these different needs. Validity and reliability were not evaluated for the AMSPSS, so it is uncertain if this measurement instrument is appropriate for this population. Comparing it to the MSPSS, a valid and reliable tool, using the AMSPSS may be suggested for future studies to measure perceived social support from teammates, coaches, and athletic trainers. A limitation of this study design was the lack of a qualitative component to understanding the athlete's perceptions of social support providers following injury and other identified life stressors. Another limitation of the study could be the more significant number of females to males and freshmen and sophomores than juniors and seniors. This limitation may have influenced the results' significance. However, the results are still an important finding in understanding the perception of social support from friends, family, significant others, teammates, coaches, and athletic trainers. 45 Future Research This study has helped identify how athletes perceive they receive the most social support following injury, illness, or other identified life stressors. No individual exclusively provides social support to the athletes; social support is perceived differently from all groups assisting the athlete. Future research could also investigate whether the athletes felt the social support was adequate or needed more beneficial support. Adding a qualitative component to the study would also help understand how the different types of perceived social support impact the athlete and their response to injury, illness, and other identified life stressors. Identifying what type of support athletes perceive from these different social support providers could also help educate the providers in the future. The support providers would better understand their impact upon the injured, ill, or stressed athlete and their various roles in the athlete's recovery from injury, illness, or other identified life stressors. The effects of gender and year of athletic eligibility on social support are still not conclusive, and examining these two factors should continue. This study specifically examined NCAA Division II athletes. It is uncertain if these results apply to other divisions or athletes in general or if these findings are unique to Division II athletes. These results would have to be explored by studies in the future. Also, instead of having athletes recall the events of a whole year of competition, it may be more beneficial to assess their stress levels across their competitive season. It is also unclear how much the response to the COVID 19 pandemic influenced the athletes' stress levels in this study. Only ten of the 546 participants specifically identified COVID 19 as their stressor. 46 References Abgarov, A., Jeffery-Tosoni, S., Baker, J., & Fraser-Thomas, J. (2012). Understanding social support throughout the injury process among interuniversity swimmers. 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Athletic Insight: The Online Journal of Sport Psychology, 7(1), 1-8. Retrieved from: http://amyburris.atspace.com/StressPDF.pdf Wu, Y., Sang, Z. Q., Zhang, X. C., & Margraf, J. (2020). The relationship between resilience and mental health in Chinese college students: A longitudinal crosslagged analysis. Frontiers in Psychology, 11, 108-120. https://doi.org/10.3389/fpsyg.2020.00108 62 Zimet, G. D., Dahlem, N. W., Zimet, S. G., & Farley, G. K. (1988). The multidimensional scale of perceived social support. Journal of Personality Assessment, 52(1), 30-41. https://doi.org/10.1207/s15327752jpa5201_2 63 Appendix A Review of the Literature 64 Comparing NCAA Division II Athletes’ Perceptions of Social Support Following Injury, Illness, or Other Identified Life Stressors. In 2016, the NCAA completed a study entitled Growth, Opportunities, Aspirations, and Learning of Students in College (GOALS) (NCAA, 2016). Two items in the survey that Division I, II, and III student-athletes completed were regarding their health and well-being and the college social experience. The NCAA (2016) reported athletes' expectations were less than accurate regarding expectations about the athletes' athletics and social experience. The NCAA (2016) noted increases in athletes who noted mental health issues such as anxiety and depression compared to the 2010 GOALS study. Only 40 percent of those athletes who reported seeking mental health assistance from team or college personnel stated they had high satisfaction levels. Almost 30% of female student-athletes reported experiencing difficulties that they had trouble overcoming in the month before completing the 2019 GOALS (NCAA, 2020b), compared to the one-quarter of male athletes who reported similar difficulties. These numbers are up for female athletes, and the numbers for males are decreasing compared to the 2016 GOALS (NCAA, 2020b). This disparity demonstrates the need for better mental health assistance and services available to male and female athletes and continues to be an issue for many college campuses. College students represent a part of our culture transitioning to adulthood, learning to live independently, and learning new coping skills (Gerlach, 2018). This unfamiliar personal growth process also comes with its challenges and is often magnified for collegiate athletes. There are more time requirements, academic responsibilities, and pressure to succeed in the classroom and athletics (Comeaux & Harrison, 2011). Thus, 65 there is increased visibility to the public, placing them in more vulnerable situations than non-athletes (Egan, 2019). In addition to these stressors, the NCAA states that “Participation in intercollegiate athletics involves unavoidable exposure to an inherent risk of injury” (NCAA, 2014, p.4). Collegiate athletes may perceive these injuries, illnesses, or other identified life stressors as threats or challenges. The response to these stressors may result in difficulty coping socially, emotionally, and physically (Acharya et al., 2018; Goodman et al., 2018). The athlete's response to stress can increase if they lack the experience, ability, and support to deal with this type of stress (Evans & Hardy, 1995). In response to these stressors, the athletes may search for support and guidance from several sources. Whether the athlete has a positive or negative appraisal of their stressors, they are most likely to share these experiences with those in their support network. (Rosenfeld et al., 1989). This support network can include friends, family, significant others, teammates, coaches, and athletic trainers (Bianco & Eklund, 2001). It is undetermined which group of individuals are most influential and likely to provide social support to the college athlete. To better evaluate which individuals a college athlete may turn to for support, it is essential to understand how individuals respond to stress and how the cognitive appraisal process operates. 66 Stress Increased stress may occur in response to an interaction, a situation, or the environment. In collegiate athletes, stress can manifest itself in several different ways. An injury, illness, or another stressor may prove an overwhelmingly negative situation for the collegiate athlete. Common emotional reactions after suffering an injury, illness, or other stressors can include anger, frustration, loss, decreased self-esteem, decreased selfconfidence, decreased mood states, and emotional volatility (Malinauskas, 2010; Tracey, 2003; Wiese-Bjornstal et al., 1998; Wilson & Pritchard, 2005). Lazarus (1990) defined stress as the following: In a transaction, a stressor taxes or demands a person's resources to appraise or react to the challenge. This transaction or appraisal of the environment, situation, or collective stressors results in the individual's appraisal of the threat of harm or challenges. The stress response occurs when the culmination of a person's assessment of the situation exceeds their available resources to meet or cope with those demands (pp. 3-4). Pensgaard and Roberts (2000) state that the amount of stress an athlete can challenge is whether or not the athlete believes these events to be within or beyond their control. If the athlete believes the stress to be within their control, then their response to that stressor will most likely be positive. If they feel the stressor is beyond their control, they are more likely to view that stressor more negatively (Pensguard & Roberts, 2000). There are several demands placed upon collegiate athletes compared to nonathletes. Like non-athletes, athletes have academic demands, social needs, and demands from friends and family. The difference is that collegiate athletes are trying to balance 67 academics and athletics commitments while also trying to meet the expectations of teammates, coaches, athletic trainers, friends, and family (Surujlal et al., 2013). When an athlete experiences an injury, this most likely results in a negative response. Injury as a Stressor Meeuwisse et al. (2003) noted that 40%-50% of athletes face at least one injury resulting in significant time loss in participation during their college years. The NCAA reported that most injuries caused three to six days of time loss from injury; however, 19.5% of injuries accounted for 21 or more missed participation days (NCAA, 2016). Those athletes who had more severe injuries also had higher amounts of perceived stress than athletes with minor or no injuries (Malinauskas, 2010). Christopher et al. (2020) noted in their study of the epidemiological profile of pain that one-half of female athletes reported pain more compared to only one-third of males. Madrigal and Robbins (2020) surveyed 525 collegiate student-athletes; 101 had current injuries. Forty-eight percent of the injured athletes attributed their stress to the injury, while the remaining attributed it to alternative stress types. Illness as a Stressor Illness, both acute and chronic, also can act as a stressor. More than 50% of acute conditions reported during athletic competitions were upper respiratory tract infections (URTI) (Schwellnus et al., 2016). URTIs can also include the following illnesses: bronchitis, pharyngitis, sinusitis, influenza, infectious mononucleosis, and pertussis (Jaworski & Rygiel, 2019). Other acute illnesses may include urinary tract infections, gastrointestinal illness, such as diarrhea, sexually transmitted diseases, and influenza (Jaworski and Rygiel, 2019). Chronic illness may consist of Diabetes Mellitus Type 1 or 68 Type 2, mental health illness, such as anxiety and depression, autoimmune disorders, such as rheumatoid arthritis or Crohn's disease (Layberger, 2019). Walsh (2016) also noted that the psychological stress response to increased training loads might also decrease the immune system's ability to fight off infection, thus increase the likelihood of illness. Other Identified Life Stressors. Malinauskas (2010) also identified life event stress as another factor impacting an athlete's life satisfaction. These life stressors can include but are not limited to academic, personal, and emotional challenges, social isolation and life, sport, and academic balance (Malinauskas, 2010; Stallman & Hurst, 2016; Watson, 2016; Wilson & Pritchard, 2005). The college athlete deals with those stressors and stressors associated with sport such as training demands, missing classes due to travel, studying, the pressure to win, and conflict with teammates and coaches (Watson, 2016). A more recently identified life stressor would be the COVID-19 pandemic. The pandemic has affected athletes in many different ways, including suspension of sports, lack of ability to train for their sport, resocialization to their sport, no live team or coach interactions, and restrictions on other activities of daily living (Pennsylvania Department of Health, 2020; NCAA 2020a). Response to the pandemic is proving to be a constant stressor and dealing with other stressors that may be present. In the case of injury, illness, or other identified life stressors, the initial reaction to these stressors can be negative (Daly et al., 1995; Mankad et al., 2009; Tamminen et al., 2016). The perception of the initial reaction may be threatening or harmful. These stressors are often unanticipated, thus making the response to that stressor more intense 69 and dangerous. The stressor's response may only occur after an athlete can perceive and cognitively appraise each stressor's meaning. 70 Perception Johns and Saks (2001) defined perception as “the process of interpreting the messages of our senses by sorting and organizing these messages to provide order and meaning (p. 207).” Bruner and Postman (1949) viewed perception as an instrumental activity influenced by motives, predispositions, and past experiences. Simply put, perception is the recognition, interpretation, and response to sensory stimuli. Bruner and Postman (1949) also view perception as a highly complex series of psychological processes that involve expectancy about an individual's environment to be true or not true. In other words, seeing what you want to see or hearing what you want to hear. Johns and Saks (2001) define this as a perceptual defense. Perceptual defense serves as a protective mechanism, so an individual does not interpret the target as threatening or harmful. Johns and Saks (2001) and Bruner and Postman (1949) suggested similar perceptual process components. There is a perceiver (person experiencing the stimulus), target (or the trigger), and the situational context in which this process is occurring. Combining the situation and target will influence the perceiver's impression or interpretation (Johns & Saks, 2001). In the Bruner and Postman (1949) model, the perceiver encounters an unfamiliar target; he/she tries to collect more information about the target, and he/she must categorize the target. In the categorization stage, cues can be ignored, distorted, and one's perception becomes more selective until he/she composes their picture of the target (Bruner & Postman, 1949). Previous experiences, emotions, and their own needs influence the perceiver's impressions of the target (Wiese-Bjornstal et al., 1998). Previously experienced injuries 71 and emotions can affect the injury's perception (the target). An athlete may experience perceptual defense as a protective mechanism, so the individual does not interpret the target as threatening or unfavorable. An individual's length of time will stay in this stage of denial depends on their cognitive appraisal and perceptions of the injury. Even though an athlete may have had the experience of an injury or other identified life stressor before, they may recall the process of injury, injury rehabilitation, return to play, and all the struggles and successes which may have occurred during that time. From a situational perspective, if an athlete has had a previous negative experience, he/she may automatically make the association that the current target will also be harmful and respond accordingly with negative emotions. Conversely, if the previous experience was perceived more confidently with positive emotions, the individual will interpret the target differently and have a more confident response. Bolling et al. (2019) suggested that injury definition and severity can be two factors in an athlete's perception of an injury. These perceptions will also impact the emotional climate of the response to injury, the injury rehabilitation process, and return to play progression. From a team perspective, emotions expressed while in team members' presence may be vastly different from those displayed when away from the group interaction. An athlete is maintaining their outward athletic identity of being strong and able to overcome anything, not imply they would need assistance from their support network results in a difference of emotions. (Mankad et al., 2009) 72 Cognitive Appraisal Cognitive appraisal is a critical component in understanding how athletes respond to stress. Lazarus and Monat (1974) defined the concept of cognitive appraisal as one which: "Expresses the evaluation of the significance of a transaction for the person's well-being and the potential for the mastery in the continuous and constantly changing interplay between the person and the environmental stimulus configuration (p. 322)." In the athletic population, athletes are part of a unique culture where athletic participation evolves around an ever-changing environment, a dynamic support network, and varying responsibilities within the team. Therefore, an athlete’s cognitive appraisal and reaction to a stressor may frequently change to adapt to their environment as their athletic, academic, and personal environment changes. An athlete’s success relies on his/her ability to identify with, adjust to and respond to this changing environment (Gayles & Baker, 2015). Every individual appraises a situation based upon their differences, which will elicit a unique response to that athlete. For example, participating in athletics may include dealing with pain, which may occur daily. As such a common occurrence, which can impact performance outcomes, playing in pain could be considered one of the more dominant cultural norms in an athletic population. (Christopher et al., 2020). Experiencing pain can occur with or without being associated with an injury. Pain may be regarded as a task threat or task challenge and depends on how the individual athlete cognitively appraises their pain. (Madrigal et al., 2016). Albinson and Petrie (2003) also examined how cognitive 73 appraisal, stress, and coping influenced athletes’ psychological adjustment before and after injury. Primary and Secondary Cognitive Appraisals Like Daly et al. (1995), Albinson and Petrie (2003) identified athletes who experience primary and secondary cognitive appraisals of their injuries. Lazarus and Folkman (1984) defined the primary appraisal as "concerning mainly the discrimination between transactions in which there are some personal investment and those that are irrelevant for the person's well-being (p. 382)." For example, an injury, illness, or other identified stressors may occur. The college athlete must decide if this stressor may affect their athletic participation or not have any effect on their athletic participation. In contrast to the primary appraisal, Lazarus and Folkman (1984) state, “secondary appraisal takes into account which coping options are available, the likelihood that a given coping option will accomplish what it is supposed to, and the likelihood that one can apply a particular strategy or set of strategies effectively (p.35)." At this point, if the college athlete feels they can accomplish a positive outcome of this cognitively appraised event, then their secondary cognitive appraisal will be positive and thus more helpful. If the college athlete feels they cannot apply any strategies effectively, this indicates a negative response and will most likely have had deleterious effects. The college athlete must go through this process of primary and secondary appraisals, often throughout coping with an injury, illness, or other identified life stressor(s). At any point in time, the appraisal can change from positive to negative, or vice versa, thus changing their coping behaviors. These processes' outcome depends on how the college athlete appraises each situation. Coping strategies were indicative of the 74 athletes' ability to appraise the injury cognitively. For example, the more negative an athlete's secondary appraisal indicated more negative emotional appraisal of the injury, the more their avoidance coping behaviors were evident at one-week post-injury (Albinson & Petrie, 2003). Previous experiences or inexperience influence the cognitive appraisals of an injury, illness, or other stressors (Wiese-Bjornstal et al., 1998). Coping and emotional responses are dependent upon one another, and the emotional reactions are unique to each individual. Roy et al. (2015) noted the initial or primary appraisal was negative in response to an athletic injury and stated this initial appraisal results from the influence of each athlete's personal and situational factors and how these affect their psychological responses to injury. Wadey et al. (2012) suggested that how an athlete copes with reinjury anxiety may have important implications for whether the symptoms manifest themselves in adaptive or maladaptive ways. These maladaptive responses included not actively participating in rehabilitation, decreased interaction with teammates, and demonstrating avoidance behaviors. Conversely, adaptive responses are more positive and mean a college athlete will be more involved in setting rehabilitation goals and continuing contact with the team and a willingness to do what they need to do to return to participation (Wadey et al., 2012). The maladaptive responses lead to an increased potential for re-injury upon return to sport participation. Several authors posit that personal factors influence cognitive appraisals (Brewer 2007; Brewer et al., 2010; Wiese-Bjornstal et al., 1998; Andersen & Williams, 1988). 75 Personal Factors Personal factors such as athletic identity, mental toughness, hardiness, and demographic qualities are related to personality, disposition, and self-perception. Brewer et al. (2010) examined the effects on athletic identity as a means of self-protective changes following anterior cruciate ligament reconstruction. Those athletes who experienced a threat to their athleticism, such as an athletic injury, may have responded by disengaging themselves from the one identity by which they defined themselves. In doing so, they reduced the threat or negative emotions they experienced from the injury (Brewer et al., 2010). Athletic Identity. Brewer (1994) defined athletic identity as the lengths a person will portray as an athlete and receive acknowledgment for their athletic prowess. Individuals with a robust athletic identity place greater importance on the role athletics plays in their lives and evaluate their overall competence or worth as a person through the lens of their athletic accomplishments (Watson, 2016). This need to place greater importance on athletics may have included any previous or present athletic experiences and athletic success or failures. Those athletes who reported stronger athletic identities were also more likely to spend their time with others who would further improve their athletic identities, such as coaches, teammates, and other athletes (Horton & Mack, 2000). Having a robust athletic identity may help athletes have a more positive cognitive appraisal of their athletic injury since they believed it to be a challenge that they may conquer. However, this athletic identity strength may also influence more negative cognitive appraisals following injury. In this case, an injury may negate their athletic 76 identity because they cannot participate in the essential thing they identify; they cannot see themselves as anything but an athlete. This lack of athletic identity may also have increased their risk for anxiety, depression, and an overall impairment to their well-being (Miller & Kerr, 2002). Tracey (2003) described decreases in athletic identity were more drastic when the participants experienced slower than expected recovery rates, rehabilitation milestones, and function was less than anticipated at the return to activity. Tracey (2003) suggested two possible explanations: athletes with months of rehabilitation ahead of them may have been slower to accept their injury status and the possibility that athletic identity tended to decrease when age increases. Regardless of how these behavioral and emotional responses manifest themselves, should they continue to escalate, it may have resulted in psychological changes which may have further impeded the recovery process. Mental Toughness. Madrigal et al. (2015) defined mental toughness as coping to maintain determination, confidence, and control under pressure. Nicholls et al. (2008) mentioned a link between mental toughness and other cognitive factors, such as coping styles, positive attitudes, and other behavioral tendencies. Guiccardi et al. (2009) identified a working definition of mental toughness as: "The presence of some or the entire collection of experientially developed and inherent values, attitudes, emotions, cognitions, and behaviors that influence how an individual approach, responds to and appraises both negatively and positively construed pressures, challenges, and adversities to consistently achieve his or her goals (p. 68)." 77 Several authors suggested that high levels of mental toughness are positively related to the problem of coping strategies and less linked to avoidance coping strategies (Andersen & Williams, 1998; Mahoney et al., 2014; Madrigal et al., 2016; Madrigal et al., 2017; Nicholls et al., 2008). Mahoney et al. (2014) examined different mental toughness interpretations between Australian workers, students, athletes, and the military. Their findings concluded that mental toughness is a characteristic adaptation to a stressor and influenced by contextual or social factors, such as coping styles and self-beliefs. Cowden et al. (2014) found similar results in their study of elite tennis players. Coaches in the Cowden et al. (2014) study identified the four most important aspects of mental toughness were: "not giving up in difficult situations'; 'having what it takes to perform well under pressure'; 'not becoming angry and frustrated when things do not go one's way'; and 'regaining one's composure if one has momentarily lost it (p. 10)". Compared to the coach, the athlete may have had a different perception of their mental toughness and the qualities of mental toughness as it relates to themselves. Hardiness. Kobasa (1979) conceptualized hardiness as another personality trait that was important to one’s cognitive appraisal of an athletic injury. Kobasa (1979) noted that individuals who had stressful life events did not experience any adverse effects on their health. The three C's of hardiness: commitment, control, and challenge, limited any negative impact on their health. Wadey et al. (2012) simplified their findings in the following way: “Individuals high in hardiness feel deeply involved in or committed to the activities in their lives, believe that they can at least partially control an event they experience, and consider change as an exciting challenge to further development (p.105)”. Chung (2012) also examined the direct and moderating effects of hardiness 78 throughout the sports injury process and had similar results. Salim et al. (2016) and Udry (1997) examined sports-related growth due to high hardiness. Those athletes who demonstrated high and low hardiness felt both negative and positive emotions at the injury time. However, those who were deficient in hardiness spent more time dwelling on their perceptions of loss and the negative aspects of their injuries and adverse effects on their sports performance than those who were high in hardiness. Those who had higher levels of hardiness could grow from their injuries because they may have an emotional outlet compared to those low in hardiness (Salim et al., 2016; Udry, 1997). Another aspect that represents the potential to influence cognitive appraisal and the injury and rehabilitative processes is the athlete's demographic characteristics. Additional Personal Factors. The demographic qualities commonly cited in the literature are age and gender (Acharya et al., 2018; Bulo and Sanchez, 2014; DeFroda et al., 2018). Abgarov et al. (2012) examined interuniversity swimmers' experience with social support throughout the injury process and considered the differences in age, gender, and different swimming abilities. These demographic differences influenced the student-athlete's response to their appraisal of the perceived interactions with teammates, coaches, and athletic therapists. In terms of gender responses, only slight differences occurred. However, the total number of participants was low (five females, seven males), and age (20-28) did not indicate a significant finding. In contrast, Mitchell et al. (2014) evaluated 319 recreational to international level athletes (258 males/61 females) with a mean age of 27.27 (SD=9.4). The authors did not identify the type of sport. Because the number of males to females was so 79 disproportionate, the authors decided not to evaluate gender. However, the authors did note that social support providers and those receiving social support should have similar characteristics to prompt more positive response to social support based on their findings. Also, the more significant number of opportunities for males' participation than females', females' experiences may have been vastly different from males. Kontos et al. (2013) examined gender differences in concussion response compared to orthopedic injuries. The females in this study tended to appraise their injuries more negatively than males. This negative appraisal was attributed to females using more active coping skills, instrumental support, and humor. Also, males reported more pressure to return to activity sooner than their female counterparts, and the authors suggest this is the result of the masculine culture associated with male sports. Gender differences were explored in many studies, with mixed results, when considering cognitive appraisal. (Druckman et al., 2019; Hawley et al., 2016; Thompson, 2010). Situational Factors Also, situational factors play an essential role in the cognitive appraisal of injury, illness, and other identified life stressors. Situational factors may include the year of athletic eligibility. Goodman et al. (2018) examined the epidemiology of shoulder and elbow injuries and noted freshman wrestlers had more elbow and shoulder injuries when compared to senior wrestlers. Increased workload, length of the season, tougher opponent competition, and not being physically or emotionally adjusted to the transition from high school to college attributed to increased injuries. Defroda et al. (2018) examined NCAA baseball players' Ulnar Collateral Ligament (UCL) injuries and also supported the theory that increased injury to younger players was due to increased workload. 80 Madrigal and Robbins (2020) noted no differences in stress when comparing academic year or year of athletic eligibility. Lan and Xuebing (2018) reported greater difficulty with freshmen's well-being and decreasing as their eligibility year increased. Conversely, Wu et al. (2020) noted that freshmen and seniors had a lower level of positive mental health. Their first year is a "transitional year" as they move from high school to college athletics for freshmen. For seniors, their stress was related to the transition from college to the working world and being completely independent. Regardless of the reason for stress, Wu et al. (2020) noted mental health education should be tailored to meet the athlete's needs depending on their year in college. Of all the factors related to sport, the most important indicator of potential problems may be when the injury occurs (pre-season, regular season, post-season play, championship tournament). Gayman and Crossman (2003) noted that the pre-season was a time for establishing "team cohesion on an emotional and physical level." As the season progresses, this bond will grow stronger amongst the team members. This time in the season is a time for athletes to prove their abilities, establish a starting role, and come together as a team unit. Injury at the end of the playing season is likely a more negative event due to the team playing to get the opportunity to play in the post-season or the individual establishing their position for the following playing season (Gayman & Crossman, 2003). This influence of the situational factors will also play a role in the athlete's psychosocial factors. Psychosocial Factors Psychosocial factors influence cognitive appraisal in several ways. This influence is mainly due to different social factors and their significance before the injury, following 81 injury recovery, and return to sport participation. Martikainen et al. (2002) defined the term psychosocial as "pertaining injury to the influence of social factors on an individual's mind or behavior, the interrelation of behavioral and social factors (p. 1091)." Psychosocial factors can also be considered any person, or to a lesser extent, the environment, which directly or indirectly affects the behavioral and emotional responses the athlete may experience. Psychosocial factors may include parents, coaches, teammates, medical staff, other friends or influences of their support system, and even the team climate. Psychosocial factors may also influence perception, cognitive appraisal, and motivation to deal with injury, illness, or other identified life stressors. Christino et al. (2015) identified self-esteem as "an overall sense of self-worth and personal value (p. 502)." Comparing a freshman to a senior athlete, the freshman may lack self-esteem as they adjust to their new environment. The senior athlete may have had higher self-esteem levels based on their age, experiences, and perceived value to the team. These two athletes may have perceived their injury differently based on these factors. The seniors will have already demonstrated their value throughout their athletic participation on the collegiate level. On the other hand, the freshman will not have had that opportunity, which could decrease their self-esteem and their athletic identity as a potential four-year contributor to the team (Gayman & Crossman, 2003). The result may be increased emotional responses for the freshman, which could later manifest in negative behavioral responses. Environmental factors, such as accessibility to rehabilitation and rehabilitation environment, also can affect how an athlete responds throughout the injury recovery and return to play (Bejar et al., 2019). Another 82 environmental factor that has had the most impact on sports has been the Covid-19 pandemic. The effect of the abrupt stopping of all athletic activity and stay-at-home orders for three months has had yet to be determined. Schinke et al. (2020) noted the ripple effect the pandemic has had on athletes and coaches and the accompanying psychological and emotional challenges for all. This situation can impact athletic identity, mental and physical health, and well-being. (Shinke et al., 2020). It is still unclear how much the pandemic has affected Division II athletes and athletes in general. The pandemic is a situational factor that has been unprecedented, and the effects are yet to be fully appreciated or understood. In addition to the environmental, situational factors and psychosocial factors may have proven to be the most impactful on motivation for the mental and physical aspects of recovering from an athletic injury. These psychosocial factors may positively or negatively affect the athlete's cognitive appraisal of the interactions between teammates, coaches, and athletic trainers. Teammates. Teammates are an integral part of the group dynamic in athletics. An injury or response to another identified life stressor by an athlete can affect the entire team. Should the athlete's injury or response to other identified life stressors render them unable to participate, the remaining teammates must now try to maintain the group dynamic's existing complexity. Campo et al. (2017) took this concept one step further and examined interpersonal regulation, defined as "emotions modulated and regulated by others" (p.380). They also examined emotion regulation, which Gross (1998), as cited in Campo et al., 2017, stated 83 as "the process by which individuals influence which emotion they have when the athlete has them, and how they experience these emotions" (p. 380). For example, if one of the starting players is injured or dealing with another identified life stressor, this can change the group dynamic. Surya et al. (2015) did qualitative interviews of male basketball players on the effects of the injury on group interactions. There was a shift in team strategies, role adjustments, perceptions of opportunity or threat, emotional climate changes, and interpersonal tension development. This shift in the team strategies and the team environment resulted in a "cascade of downstream effects" (p. 62). An injury to one athlete can upset the entire team environment. Everyone is now learning their new roles and can create more dysfunction within the team than before the injury or other identified life stressor. Robbins and Judge (2010) anticipated there would be conflicts within the group at some point in time. Evans et al. (2012) attribute this intragroup conflict to the fact that athletes are so intertwined in the group dynamics of the team by sharing the same experiences, meanings, and goals that an injury, illness, or other life stressors experienced by a teammate may have influenced the social processes of the group. The group also affects the social processes of the injured or stressed individual. This conflict within the group is defined best by Wall and Callister (1995): "conflict is a process by which one party perceived that its interests are being opposed or negatively affected by another party (p. 517).” Throughout this change in the group dynamic, the athlete-coach relationship was also instrumental in dealing with illness or other identified life stressors and how the 84 remaining team members responded to the athlete's vacancy in team activities (Surya et al., 2015). Some teammates may resent the injured, ill, or athlete responding to another identified life stressor because their roles on the team have now changed. Coaches. How a coach leads the team may change based on different personal and environmental factors (Kim & Cruz, 2016). A player's satisfaction may increase and improve the cohesion of the team. Amorose and Nolan-Sellers (2016) stated the quality and frequency of encouraging words and actions of the coach improved the athletes' perceptions of competence. Noble et al. (2016) said that perceptions of confidence and motivation are a product of their surrounding environment. The coach created this environment and exercised control over the individual athletes and team's culture. Jowett (2017) stated, “the coach and the athlete need one another to develop, grow and succeed” (p. 3). This interdependence affects and is affected by how each part of this team concept thinks, feels, and behaves. Therefore, one part of the team is not more important than the other; they need each other to succeed. Without the dyadic relationship, neither party can grow and expand their knowledge or enhance their performance. Davis and Jowett (2014) suggested an effective coach was responsive to the athlete's needs, provided advice and guidance, and supported the athlete's autonomy. Davis and Jowett (2014) also stated the coach represented a target for proximity, a safe haven, and a secure base. With this type of athlete-coach relationship, the coach can be an ally with the athletic trainer as they both assisted the athlete following injury. This third party is needed to foster this relationship of positivity, growth, and communication. 85 Athletic Trainers. Athletic trainers are often the first person to whom athletes turn to when they experienced the emotions commonly associated with injury (Clement et al., 2015; Yang et al., 2010). Injured athletes also felt they had a stronger rapport with athletic trainers than coaches, teammates, or significant others when dealing with an injury (Clement & Shannon, 2011). In a study by Unruh et al. (2005), college athletes evaluated their satisfaction with their athletic trainer. High-profile sports reported more satisfaction with their athletic trainer when compared to low-profile sports. Females who participated in high-profile sports also reported higher satisfaction when compared to males in lower-profile sports. Unruh et al. (2005) suggested: "treating all athletes with dignity and respect, providing emotional support and considering each athlete's perspective (p. 55)" as a way to improve the interactions between athletic trainers and athletes. Ryan and Deci (2000) suggested the three basic needs be met when increasing one's motivation were: autonomy, competence, and relatedness. To improve an athlete's motivation to recover emotionally and physically from an athletic injury, athletic trainers must utilize these strategies when dealing with injured athletes. Athletic trainers must provide an environment where they and the athlete provide meaningful and reciprocal input, have the confidence in their ability to treat the whole athlete, and create the sensation of being valued and cared for by others (Unruh et al., 2005). Surya et al. (2015) also noted that the interactions' frequency and quality might influence the athlete's cognitive appraisal and psychosocial responses to injury. An athletic trainer is in the position to do just that, as they will, in most collegiate settings, have daily one-to-one contact with the injured athlete. In this way, athletic trainers can 86 influence the psychosocial reactions to injury and provide much-needed social support to the injured athlete. Robbins and Rosenfeld (2001) suggested that athletic trainers provided more social support to the injured athlete than coaches and assistant coaches. Athletic trainers offered different types of resources throughout the injury, injury rehabilitation, and return to play progression of the injured athlete. Bennett et al. (2016) suggested the athletic trainer was a stakeholder in the sports environment and compared their function as a comprehensive rehabilitation manager. Therefore, the athletic trainer is responsible for the physical rehabilitation aspect of injury recovery and the psychological aspect. These responsibilities facilitate an atmosphere where the student-athlete perceived a positive environment to rehabilitate their injury. Not only are the sport-related support networks critical, but support from friends, family, and significant others has provided social support to the athlete who is suffering from injury, illness, or other identified life stressors. Friends. Sullivan et al. (2020) found that teammates and "non-athletic persons" were both significant sources of social support. Friends, for this research, were considered people athletes had a relationship with and were not related to their sport participation, such as their teammates. Covassin et al. (2014) compared those athletes who had suffered a concussion to those who had orthopedic injuries and identified as support providers. The concussed group was most satisfied with the support they received from friends, family, and teammates, respectively, compared to coaches, athletic trainers, and physicians. The orthopedic injury group was more satisfied with the overall support from 87 family, friends, and teammates than from athletic trainers, coaches, and physicians. Studies have shown similar results, where friends, family, and teammates had provided more social support (Wiese-Bjornstal et al., 1998; Yang et al., 2010). However, other studies have shown that athletes were more satisfied with the social support they received from coaches, athletic trainers, and physicians (Bianco & Eklund, 2001, DeFreese & Smith, 2014; Newman & Weiss, 2017; Tracey, 2003). Sullivan et al., 2020 refer to friends and family as "built-in support systems" unique to each athlete. Family. Many athletes may turn to their family members for social support following an injury. Clement et al. (2015) noted that NCAA division II athletes had fewer resources available to them in terms of coaches and athletic trainers and therefore had to rely more on family and significant others for social support. Poucher et al. (2018) examined female Olympian athletes' social support networks. They reported that athletes did not want informational support from their families but needed more emotional and tangible support. This need for more emotional and tangible support was also the case in the study conducted by Wyament and Huffman (2020). Family members are generally very close to the athlete, as they have been a part of their lives until this point and have intimate knowledge of how they typically respond to stress. Significant Others. Poucher et al. (2018) also note that significant others were said to know each other for seven years before the athletes needing support. Significant others also provide meaningful social support to those individuals who are coping with injury or stress (Freeman, 2020; Mitchell et al., 2014; Agbarov et al., 2012; Fletcher & Sarkar, 2012). Freeman (2020) also notes that social support is more beneficial when provided by an individual who has expertise and similarity to the individual receiving the 88 support. Also, the provider should share a similar identity to the person who is the receiver of the social support. A significant person could be considered a close friend, a romantic partner, or even an athletic trainer or other professional. Regardless of who they are, they provide more meaningful social support than just an acquaintance would. No matter the athlete's relationship, the individual(s) who provide social support are essential in how an athlete copes with injury, illness, or other identified life stressors. Personal factors, situational factors, and psychosocial factors indicate the complexity of the social support provided by their support networks. 89 Social Support Hagiwara et al. (2017) stated that social support occurs between individuals who have had, on some level, an interpersonal relationship, and the social support was an interactive experience between these individuals. Shumaker and Brownell (1984) identified social support as "an exchange of resources between two individuals perceived by the provider or recipient to be intended to enhance the well-being of the recipient" (p. 21). Yang et al. (2010) defined social support for an athletic population as an "athlete's appraisal of the support that might be available to them from their social network and how satisfied they were with that support (p. 374)." Regardless of the definition used, social support's primary function is to improve the receiver's well-being (Hardy et al., 1991; Udry, 1997; Rees et al., 2010; Poucher et al., 2018, Yang et al., 2015). Wiese-Bjornstal et al. (1998) suggested social support can modify an athlete's cognitive appraisal and influence the resulting psychosocial behaviors, which is a combination of emotional and behavioral responses. See Figure 1. for Bianco and Eklund's (2001) conceptional map of social support. 90 Figure 1 Conceptual Map of the Social Support Process PROVIDER AND RECIPIENT CHARACTERISTICS Sociocultural Context Relationship Characteristics SOCIAL SUPPORT Structural Features (Support Networks) Functional Features (Support Exchanges) Instrumental Goals Relief from Distress Enhanced Coping Perceptual Features (Support Appraisals) Relational Goals Relationship Formation Relationship Maintenance Stress-Buffering Effect Main Effect Palliative Pathway Preventative Pathway IMPROVED HEALTH AND WELL-BEING Figure 1. Conceptual Map of the Social Support Process. From “Conceptual considerations for social support research in sport and exercise settings: The case of sport injury.” By T. 3 (Bianco and R.C. Eklund, 2001. Journal of Sport and Exercise Psychology, 23(2), p. 88. https://doi.org/10.1123/jsep.23.2.85 91 Types of Social Support Richman et al. (1993) reference eight types of social support identified by Pines et al. (1981). They are the following: listening support, emotional support, emotional challenge support, reality confirmation support, task appreciation support, task challenge support, tangible support, and personal assistance. Listening support is the perception that someone is listening but does not advise or provide judgments on one's activity. Emotional support is the perception that someone will provide comfort and caring and indicate that they are on the athlete’s side. (Richman et al., 1993) Emotional challenge support is the perception that someone is challenging the athlete to re-evaluate their feelings and attitudes. Reality confirmation is the perception of the receiver of support that the provider of the support has values similar to their own and can confirm the receiver’s perceptions (Richman et al., 1993). Richman et al. (1993) defined task appreciation as the perception that someone acknowledges and supports the receivers' determination and expresses their gratitude for their efforts. Task challenge challenged the receiver to re-evaluate their thoughts on a task or activity to motivate and positively respond to the task at hand. Tangible assistance occurred when another individual provides the receiver with monetary support, gifts, or other concrete awards (Richman et al., 1993). Personal assistance provided the receiver with services or help, such as helping with daily living activities. Richmond et al. (1993) noted the following to be essential items to consider in the acquisition of social support: "the recipient of the support, the provider of the support, the interactional exchange process between the provider and recipient, and the outcomes of the exchange process (p. 291)." 92 Berg and Warner (2019) referred to social support as more of a sense of community that is an essential factor for athlete development. Social support can be an integral influence on first-year non-athlete university students' physical activity (Scarpachia et al., 2017). In a study by Deliens et al. (2015), lack of social support was identified as one of the influencing variables that impeded participation in physical activity in non-athletes. Suppose non-athlete university students struggle to have adequate social support from their support network. In that case, it only stands to reason that there would be similar, if not higher, levels of decreased social support available for collegiate student-athletes. Perceived Social Support Perceived support was crucial in athlete's psychological well-being by several researchers (Cranmer & Sollitto, 2015; DeFreese and & Smith, 2014; Gabana et al., 2017; Hornstein & Eisenberger, 2017; Jeon et al., 2016; Lakey et al., 2015; Malinauskas & Malinasukiene, 2018). Gabana et al. (2017) examined the mediating role of social support and its effects on gratitude, burnout, and sport satisfaction among college athletes. Lambert et al. (2009) define gratitude as the "recognition of the value of a benefit or that one has received a valuable benefit from others (p. 274)." Gabana et al. (2017) also noted that gratitude could improve one's ability to retrieve those positive memories from their thought-action repertoires, adding to their ability to have more social support resources and overcome future hardships. These positive memories also influenced their perceptions of received support. Those individuals who were grateful were more appreciative of the support versus those who were ungrateful, as they perceived the support as being more harmful and less helpful. 93 Hornstein and Eisenberger (2017) concluded from their study that social support prevented the development of fear associations, therefore reducing threat-related stressors. DeFreese and Smith (2014) also noted that social support positively contributed to well-being across the competitive sports season. Malinauskas and Malinasukiene (2018) reported a significant relationship between emotional intelligence and perceived social support on athletes' well-being. Those athletes who scored higher in emotional intelligence reported increased social support perceptions, leading to improved emotional well-being. Lakey et al. (2015) also note that ordinary social interaction was the main effect between perceived social support and positive affect. Therefore, any positive social interaction would be likely to improve well-being. Jeon et al. (2016) concluded that selfcompassionate attitudes mediated the role between social support and subjective wellbeing in elite Korean athletes. Based on the differences and similar findings in these studies, it is clear the amount of perceived support can have a positive effect on subjective well-being. Again, many authors caution that social support can have a detrimental impact on the athlete's well-being if perceived negatively and unhelpful (Bianco & Eklund, 2001; Sarason et al., 1994; Abgarov et al., 2012; Mitchell, 2011). Social support effects occur through several processes. Mitchell (2011) noted several different factors might complicate social support processes, such as two of the primary effects of perceived social support: the stress-buffering and the main effects processes. 94 Stress-Buffering Process The stress-buffering process is considered an integral component of the stressinjury relationship (Hartley & Coffee, 2019; Hornstein & Eisenberger, 2016; Lakey et al., 2015; Lu & Hsu, 2013; Mitchell et al., 2013; Andersen & Williams, 1998; Yang et al., 2010). In simple terms, the stress-buffering hypothesis states that social support acts as a buffer or mediator between individuals and their psychological and physiological threat responses and perceived social support (Hornstein & Eisenberger, 2016, Lakey et al., 2015; Mitchell et al., 2014). Cohen and Wills (1985) state that the stress-buffering effect is a process of support that protects an individual from the potential of adverse events in response to stress. For instance, an athlete dealing with the stress of an injury and their ensuing psychosocial and physiological responses to the injury will look to their social support network for assistance in dealing with these responses. The buffering effect effectively reduces the stress response if the perceived social support matches injury responses (Cohen & Wills, 1985). Stress-buffering also decreases the frequency of burnout, which is the inability to meet sport's physical and psychological demands (Bianco & Eklund, 2001; Cohen & Wills, 1985; Hartley & Coffee, 2019; Mitchell et al., 2014). This model is most effective when the individuals, such as teammates, coaches, and athletic trainers, who are giving the support are closest with the individual under stress (Hornstein & Eisenberger, 2016). In contrast to the stress-buffering process, the main effects model suggests received social support is more important than perceived support. 95 Main Effects Model The main effects model suggests that social support received will directly affect the individual, whether or not the athlete is experiencing higher or lower stress levels (Bianco & Eklund 2001; Cohen & Wills, 1985; Hartley & Coffee, 2019). The main effects model will also result in a decreased response to a stressor and increase one's ability to cope with stress (Mitchell et al., 2014). However, Mitchell (2011) suggests the main effects of received support may not be as impactful as the buffering effects of perceived support. Injury in collegiate student-athletes represents a change in the usual feelings of well-being in a healthy athlete. At this point, their perception of support and received support can vary, as can the individuals from whom they seek this support. Bianco and Eklund (2001) also noted that athletic injury impacts the social support activities and support messages, the support networks, support behaviors, and appraisals of support. Bianco and Eklund (2001) also caution that support activities may not always result in the desired positive response. Self-Efficacy Another essential component of social support and injury recovery is selfefficacy. Bandura (1997) has defined self-efficacy as "beliefs in one's capabilities to organize and execute the courses of action required to produce given attainments" (p. 3). It is a concept which Bandura (1997) proposed is task-centered, affects a person's decision making, level of persistence, and effort expenditure. Lazarus (1980) suggests individuals will fear aversive events due to inefficacy, which leads to decreased performance. Bandura (1983) states, "the less efficacious subjects judge themselves to be, 96 the more fear they experience when they later perform the threatening task (p. 466).” Conversely, suppose individuals have increased self-efficacy and believe they can exercise control over an aversive event. In that case, they are more likely to have minor impairment in completing the task and improve performance outcomes. As a person responds to a stressor, their self-efficacy will have either positive or negative physiological, behavioral, or psychological responses, which, in turn, will affect one’s mental health (Schönfeld et al., 2017). Bandura (1997) also suggests four sources of self-efficacy: the direct influence of personal experiences of success and mastery; observations of social models which succeed or fail; encouragement by verbal persuasion that can alleviate doubts and foster the belief that one can achieve their desired goals, and the interpretation of physiological reactions to stressors. In the sports context, this could be considered the ability to apply previous experiences with injury and skill mastery and apply these experiences to the athlete’s current injury or other identified life stressor. The verbalized support from coaches, teammates, and athletic trainers that the athlete receives can allow the athlete to reach their goals and overcome the physiologic reactions to the stressful situation, such as the injury, illness, other identified life stressor, or even rehabilitation. This verbalized support illustrates the importance of social support and its influence on whether an individual interprets a positive or negative stressor. McCann and Gribble (2016) explored the impact of self-efficacy on the rehabilitation from lateral ankle sprains. They suggest that the environmental factors and social attitudes surrounding themselves influence a patient's perceived ability to cope with an injury. Social attitudes can include the team members' and coaches' sports culture and attitudes, positively or negatively influencing the injured athletes. Positive attitudes 97 would lead to better rehabilitation adherence, and negative attitudes would lower rehabilitation adherence. Sari and Bayazit (2017) also concluded in their study between perceived coaching behaviors, motivation, and self-efficacy in wrestlers. These authors suggested that individual characteristics, such as sports experience and gender, and family attitudes about sport may also affect the perceived social support behaviors and intrinsic motivation for athletes to excel. Sari and Bayazit (2017) caution that this support may also be detrimental to performance and depends on the individual. There are many different factors to consider in athletic participation, and an injury, illness, or other identified stressors can bring participants to a screeching halt. The stressor may have either positive or detrimental effects on the athlete, depending on their cognitive appraisal, perceptions, and support systems. To better explain the response to stressors and one's cognitive appraisal of the stressor, several authors have developed their theoretical models to explain these concepts (Andersen & Williams, 1988; Brewer, 1994; Brewer et al., 2002; Kubler-Ross, 1969; Wiese-Bjornstal et al., 1998). 98 Theoretical Models There are several different models which address how athletes respond to athletic injury. These models include the stage model (Kubler-Ross, 1969); the stress and injury model (Andersen & Williams, 1988); the cognitive appraisal model (Brewer, 1994); the biopsychosocial model (Brewer et al., 2002) and the integrated model of response to sports injury (Wiese-Bjornstal et al., 1998). These models share similar components; however, there are also some differences between models. Table 11 shows a comparison of the models and what factors make up each model. 99 Table 11 Comparison of Theoretical Models Coping Resources Anger Denial Bargaining Depression Acceptance Pre-Injury Factors Stress Response Sport Injury Personal Factors Situational Factors Cognitive Appraisal Behavioral Response Emotional Response Recovery Outcomes Physiological Psychological Biological Biopsychological Psychosocial Stage Model Kubler-Ross, 1969 X X X X X Stress-Injury Model Andersen & Williams, 1988 X X X X X X Cognitive Appraisal Model Brewer, 1994 X X X X X X Integrated Model of Response to Sport Injury WieseBjornstal, 1998 X X X X X X X X X X X X Biopsychosocial Model Brewer, 2007 X X X X X X X X X X X X X X 100 Comparison of Theoretical Models At the core of all five theoretical models of response to injury is the cognitive appraisal. The Stage Model by Kubler-Ross (1969) does not explicitly recognize cognitive appraisal as a factor. However, when dealing with emotions in response to a stressful event, there must be some level of cognitive appraisal. Cognitive appraisal in all the other models acts as a means to identify and understand the emotions one is experiencing (Andersen & Williams, 1988; Brewer, 1994; Brewer, 2002; Lazarus & Monat, 1974; Wiese-Bjornstal, 1998). After cognitively appraising the event, the models concur that an emotional response occurs as a response to the injury, illness, or other identified life stressor. The appraisal and response process may be slightly different in each model and may influence this appraisal. All authors agreed that the response to these factors could positively or negatively impact the continuing process of cognitive appraisal and injury recovery and the response to stressors. (Andersen &Williams, 1998; Brewer, 1994; Brewer et al., 2002; Kubler-Ross, 1969; Wiese-Bjornstal, 1998). The level of importance these influences have on an athlete's response to injury and stress varies slightly between models. For instance, the cognitive appraisal model focuses on the perception of an event and the cognitive appraisal afterward. The cognitive appraisal theory does not elucidate the impact these appraisals will have on the injury appraisal and outcomes compared to the biopsychosocial and integrated models. In the biopsychosocial and integrated models, perception and cognitive appraisal occurs first and then supports these appraisals' influences on the injured or stressed athlete's personal and situational factors. In contrast, the stage model only focuses on the different response stages following the injury but 101 does not explore the influence of perception and cognitive appraisals. However, these must occur to progress to the next step. In the cognitive appraisal, biopsychosocial, and integrated models, the individual's unique assessment of the injury or stressor is essential. There is recognition of personal and situational factors' level on the cognitive appraisal. The cognitive appraisal and biopsychosocial models do not associate these responses to previous stressors and personal factors before the event's cognitive appraisal. In contrast to these models, the integrated model considers the strong influence of earlier factors on how individuals will cognitively appraise each injury or stressful event. The Integrated Model of Response to Sport Injury The Integrated Model of Response to Sport Injury (Wiese-Bjornstal et al., 1998) is a combination of the cognitive appraisal model first introduced by Brewer (1994), the stress and injury model suggested by Andersen and Williams (1988), and the psychological response to athletic injury and rehabilitation theory proposed by WieseBjornstal et al., (1995). The Integrated Model by Wiese-Bjornstal et al. (1998) resulted from blending these three models. Refer to Figure 2 for a schematic of the Integrated Model of Response to Sport Injury. In the Wiese-Bjornstal et al. (1995) model, response to athletic injury and rehabilitation follows cognitive appraisal and response. There is a cyclical stress-response progression, which occurs continually throughout the rehabilitation process, as recovery is at the center of this progression. The emotional and behavioral responses will continue to impact the recovery from injury and throughout the rehabilitative process. There are mediators (personal and situational factors) and 102 moderators (coping resources, stressors, intervention, personality), which impact the response to injury and rehabilitation. Figure 2 The Integrated Model of Response to Sport Injury “Integrated Model of Response to Sport Injury.” From “An integrated model of response to sport injury: Psychological and sociological dynamics,” D.M. Wiese-Bjornstal, A. M., Smith, S. M., Shaffer, and M.A.Morrey. 1998, Journal of Applied Sport Psychology, 10(1), p. 49. https://doi.org/10.1080/10413209808406377. Image courtesy of Open Learn https://www.open.edu/openlearn/ocw/mod/oucontent/view.php?id=85696&extra=thumbnailfigure_idm45931025697280 In the Wiese-Bjornstal et al. (1998) Integrated Model of Response to Sport Injury, the emotional and behavioral responses act as more contributors to the recovery outcomes. These responses will continue to change as all the factors impact one another. 103 Thus, the response to injury will have multiple cognitive appraisals and emotional reactions to those appraisals throughout the response to injury, illness, or other identified life stressors. The cognitive appraisals, emotional and behavioral responses may affect recovery outcomes. An injury appraisal goes one step further than the other models in the Integrated Model. It identifies pre-existing factors such as coping resources, previous injury or stressors, and the individual's personality and how this collectively influences each athlete's personal and situational factors. How these responses will affect the recovery outcomes are the emphasis. The cognitive appraisal model and biopsychosocial model suggest that the personal and situational factors only influence the response to injury or stress. The most significant difference in the Integrated Model compared to the other models is that the model notes that perception and cognitive appraisal will elicit and influence emotional and behavioral responses. This influence will continue to evolve and change, as perception and cognitive appraisal are changing rapidly throughout the injury, illness, or stress process and return to activity. The biopsychosocial and cognitive appraisal models do not recognize the influences of the perceptions and appraisal of the injury or stressor on interventions. The Integrated Model distinguishes this as an essential factor. Walker and Heany (2013) noted a limitation of the Biopsychosocial Model compared to the Integrated Model. It lacked a description of the relationships between psychological factors such as the psychologically-based models. However, this model does go into greater detail about the influence of biological, social, and psychological 104 inputs during the rehabilitation of a sports injury (Brewer et al., 2002). One model is not better than the other; however, Walker and Heaney (2013) caution that the biopsychosocial model does not have as much research supporting its use in the athletic environment as the Integrated Model. Although the Integrated Model does not include the biological element, its application in athletes' context has been more widely used and accepted as a more appropriate model to address this population's needs. (Albinson & Petrie, 2003; Clement et al., 2015; Bianco & Eklund, 2001; Conti et al., 2019; Roy et al., 2015). WieseBjornstal et al. (1998) also noted the "depiction and discussion of this model would continue to evolve as elements are tested (p. 48)." Therefore, for this study, the concepts and properties represented in the Integrated Model of Response to Sport Injury are referenced. In the Integrated Model, perception and cognitive appraisal are vital components to how an athlete copes with an athletic injury. The combination of cognitive appraisal and perception will influence emotional, psychological, and behavioral responses following exposure to a stressor and injury. Andersen and Williams (1988) suggest the process of cognitive appraisal can last "from weeks to months." In contrast, the Integrated Model offers cognitive appraisals are fluid and continuously changing process. The changing functions are attributed to appraisals or self-perceptions because both factors will continually impact the emotional and behavioral responses to athletic injury, illness, and stress. One of the more essential components of applying these theoretical models is having a measurement scale or instrument to identify which stage of the model an athlete 105 may be going through at any given time. None of the models have an instrument that can evaluate every stage of the model. Considering every stage may not be necessary to identify the model; however, it can be an essential piece of the puzzle in understanding an athletes' perceptions and cognitive appraisals of an adverse event. Evaluation of social support has used several different instruments; however, no instrument is used exclusively for social support and athletes. Measurement Instruments Over the previous decades, there have been many different instruments measuring social support. The Social Support Questionnaire developed by Sarason et al. (1983) measures those individuals to whom an individual can turn to and rely on for social support and indicates the satisfaction of the social support received. On a similar scale, The UCLA Social Support Inventory (Dunkel-Schetter et al., (1986) measured the needs of social support, the extent to which support was sought out and received, and the satisfaction of this support. Compared to the Social Support Inventory developed by Brown et al. (1988), it measures social support resources' adequacy. Sherbourne and Stewart developed the Medical Outcomes Study Social Support Survey (MOS-SSS) in 1991. This instrument was used with patients suffering from chronic conditions, such as diabetes. This survey measured emotional, informational, tangible, affectionate, and positive social interactions. These scales' common factor is they do not address the athletic population's unique needs for social support. Richman et al. (1993) developed the Social Support Survey (SSS). The Social Support Survey evaluates the recipient, interactions, outcomes, and understanding of the social support process. Athletic populations have used this instrument, but it has not been 106 used explicitly with an athletic population. Bianco and Eklund (2001) suggested social support measures should be relevant to the population they are assessing. The Perceived Available Support in Sport Questionnaire (Freeman et al., 2011), explicitly designed for an athletic population, measures the following four types of social support: emotional, esteem, informational and tangible. It also measures the perceived types of support which one would subjectively identify from friends, family, teammates, and coaches. However, this test's weakness was the lack of consistent and acceptable reliability and validity. This instrument's use with an athletic population has not been widely used (Gabana et al., 2019; Freeman et al., 2011). Multidimensional Scale of Perceived Social Support (MSPSS) The MSPSS, developed by Zimet et al. (1988), remains a widely used instrument. The purpose of the MSPSS is to subjectively assess social support and social support adequacy from three distinct sources: family, friends, and significant others. The MSPSS was found to have good reliability, factorial reliability, and construct validity (Zimet et al., 1988). This instrument has been modified and adapted to be cross-culturally accessible and administered to various populations while still retaining its validity and reliability. In terms of validity and reliability, one study included comparing perceived social support of pregnant women, adolescents living in Europe with their families and pediatric residents (Zimet et al., 1990); clinical nurse specialists (Hardan-Khalil & Mayo, 2015); Hispanic college students (Ermis-Demirtas et al.,2018) and university students (Guan et al., 2015). From 1995 to 2016, there were over 20 different language translations to the 107 original survey, and the MSPSS continues to maintain its reliability and validity (Dambi et al., 2018). The MSPSS is the most commonly used measurement of social support. Athletic Multidimensional Scale Perceived Social Support (AMSPSS) Use of the AMSPSS has not occurred in any research before this study. The primary researcher modified it to measure the perceived social support an athlete receives from teammates, coaches, and athletic trainers following injury, illness, or response to other identified life stressors. Teammates, coaches, and athletic trainers represent whom athletes will often turn to for support (Bennett et al., 2016; Malinauskas & Malinauskiene, 2018; Mankad et al., 2009; and Newman & Weiss, 2017). Malinasukas and Malinasikiene (2018) examined the relationships between emotional intelligence, well-being, perceived social support, and perceived stress in 398 male athletes. The authors used the MSPSS and the PSS to measure perceived social support and perceived stress, respectively. Malinasukas and Malinaskikiene (2018) found that perceived social support and perceived stress mediates the relationship between emotional intelligence and well-being. This relationship's mediation may be attributed to individuals with higher levels of emotional intelligence. They are more adept at recognizing and managing other individuals' emotions, and therefore will be better equipped to seek social support. This process will then result in greater feelings of wellbeing for the individual. Malinasukas (2010) found that perceived social support and perceived stress did not influence athletes' well-being with minor injuries, but perceived social support and stress affected athletes' well-being with significant injuries. Perceived stress and social support from family and friends were influential in predicting the feelings of well-being 108 in athletes with significant injuries. The higher the perceived stress and the less social support perceived from friends and family, the more the decrease in the athlete’s feeling of well-being, and vice versa. Other authors have also supported these findings (Bianco & Eklund, 2001; DeGroot et al., 2018; Malinasukas & Malinasikiene, 2018). Based on these studies' results, which utilized the MSPSS and the PSS-10, these instruments would be a good fit to address the influence of injury and stress on perceived social support. University Stress Scale (USS) Stallman and Hurst (2016) developed the USS, which measures the stress and intensity of college students' specific stressors. The USS, comprised of 21 specific academic categories, and the instrument examines are the following: academic/coursework demands, procrastination, university environment, finances/money problems, housing, transportation issues, mental health issues, physical issues, issues with friends, family, and relationships, parental expectations, study/life balance, discrimination, language/cultural issues, and other demands (Stallman & Hurst, 2016). The USS, used in several different studies, notes the Chronbach’s alpha to be between .80 to.84 (Kyani et al., 2018; Lyvers et al., 2019; Stevens et al., 2019). While these stressors are not a comprehensive or all-inclusive list of stressors that may occur in a college student's life, this list represents the more common stressors that college students may experience. Perceived Stress Scale-10 (PSS) The PSS was not explicitly designed for athletes but is used with populations with at least a junior high education (Cohen et al., 1983; Cohen & Williamson, 1988). The PSS measures how much perceived stress is associated with different situations in an 109 individual's life. The questions are structured to be very general in their content, allowing their use across diverse populations versus being more specific, narrowed questions that a large population would not necessarily use. This non-specific quality makes this instrument one of the most widely used to assess perceived amounts of stress in an individual (Denovan et al., 2019; Othman et al., 2019; Sun et al., 2019). The foundation of PSS's success is the design to identify how unpredictable, uncontrollable, and overloaded respondents find their lives (Cohen et al., 1983; Cohen & Williamson, 1988). The PSS measures the stress experienced in the month before testing. Other authors have made no modifications to investigate perceived stress in the 12 months before the instrument is administered. Since the PSS has proven to be a reliable and valid instrument (Malinasukas, 2010; Malinasukas & Malinasikiene, 2018; Othman et al., 2019; Sun et al., 2019), especially in combination with the MSPSS, there is adequate evidence that supports the use of these three instruments in the present study. This combination of instruments may help identify weaknesses within an athlete's support network and better understand the more common stressors and the perceived stress that athletes are dealing with in their personal lives and how this affects their athletic participation. Also, the instruments may help identify social support levels to these athletes in need, thus improving their well-being and athletic performance. 110 Conclusion From Kubler-Ross’s (1969) initial identification of a theoretical model to clarify how an athlete responds to an injury using the stage model, to the Wiese-Bjornstal et al., (1998) Integrated Model of Response to Sport Injury, the concepts of cognitive appraisal and social support have continued to evolve. Athletes' perception, athletic identity, mental toughness, and hardiness represent this population's unique attributes compared to non-athletes. These attributes develop for many years by dedication to the sport of one's choice. The athlete, teammates, coaches, athletic trainers, friends, family, significant others, and other people in the athlete's social support network and their interactions form the athlete's environment. All these individuals help shape the perceptions and influence both the individual athlete's emotions and behaviors. Injury, illness, and other identified life stressors represent an abrupt change to this environment, thus altering the athlete's perceptions, appraisals, and responses. Collegiate athletes must also deal with these stressors and learn to cope with them while still maintaining their athletic identity. It has yet to be determined if these other identified life stressors have the same impact on the collegiate athlete as an injury or illness would. The importance of social support to these stress responses in the athletic population is examined. By adjusting the timing and type of social support, the athlete can reduce the severity of their emotional and behavioral responses. These lessened responses may help improve their response to athletic injury, illness, and other identified life stressors and possibly return to sport with less emotional and physical difficulty. To identify the effectiveness of these interventions, using a measurement instrument that explicitly addresses this unique population would be advantageous. The 111 AMSPSS was adapted from the MSPSS by the primary researcher to address athletes specifically and identify individuals in the sport context who are most likely available to offer social support- teammates, coaches, and athletic trainers. Using this measurement instrument on athletes, especially those in the collegiate setting, may allow for more proactive actions to be taken before and following injury, illness, or response to other identified life stressors to help them cope with these stressors. This study aims to compare support providers in an athletic environment to social support providers outside of the athletic context. Using the three subgroups identified in the MSPSS and the AMSPSS accomplishes this comparison. The subgroups include friends, family, significant others, teammates, coaches, and athletic trainers. Examining similarities or differences between these six subgroups and the perceived social support provided to the athletes will occur. Therefore, these comparisons will drive the hypothesis that there will be more significant amounts of perceived social support from teammates than friends, coaches compared to family, and athletic trainers compared to significant others following injury, illness, or other identified life stressors. 112 Appendix B Problem Statement 113 Problem Statement The NCAA Sports Medicine Handbook (2014) states, “Participation in intercollegiate athletics involves unavoidable exposure to an inherent risk of injury (p.4).” When an athlete experiences an injury, they may perceive the injury negatively, see it as a threat; or appraise it positively and perceive it as a challenge. Cognitive appraisal influences perception, which Lazarus (1982) defined as the means to mediate the relationship between an individual and their environment. This process is fluid and continually changing based on an athlete’s perception of their environment. The Integrated Model of Response to Sport Injury best represents the process developed by Wiese-Bjornstal et al. (1998). In this model, demographics, personal and situational factors, previous injury experience, and social support experience influence the perception of injury and proceeding cognitive appraisals (Burland et al., 2018; Russell & Wiese-Bjornstal, 2015). The collegiate athlete, identified by Malinasuskas & Malinauskiene (2018), identified social support networks are family, friends, teammates, coaches, and athletic trainers. Bianco and Eklund (2001) and DeFreese and Smith (2014) identify the individuals who the collegiate athlete is more likely to reach out to those they have the most in common teammates, coaches, and athletic trainers. Collegiate athletes are in a unique situation, where they may not have as much access to friends, family, or significant others when compared to the more immediate availability of teammates, coaches, and athletic trainers. The NCAA has been working towards improving athlete well-being to support the ultimate goal of enhancing the athlete's academic and social development (NCAA, 2019). This social environment can make a difference in an injury's perception and cognitive appraisal. Therefore, it is 114 essential to identify those individuals who recognize their social support network following injury, illness, or other identified life stressors. Identifying athletes' social support networks may help practitioners gain a more thorough understanding of how they perceive social support from those closest to them. Understanding athletes' social support networks may also help develop strategies to assist those athletes who need social support following injury, illness, or responding to other identified life stressors. Therefore, the hypothesis driving this research is there will be more significant amounts of perceived social support from teammates than friends, coaches compared to family, athletic trainers compared to significant others dependent upon injury status, illness, and other identified life stressors. 115 Appendix C1 Additional Methods Collegiate Athletes’ Perceptions of Social Support Survey 116 PERCEPTIONS OF SOCIAL SUPPORT: PART I Informed Consent Letter Dear PSAC Athlete: This survey has been approved by the California University of Pennsylvania Institutional Review Board. This approval is effective nn/nn/nn and expires mm/mm/mm. Please read through this informed consent in its entirety to make sure you fully understand the purpose of the study and your role in the study should you agree to voluntarily participate. Introduction You are invited to participate in a research study which is designed to get a better understanding of who PSAC athletes seek out for social support following injury, illness or other life stressors. You are eligible to participate if you are 18 years of age or older and are currently rostered on an NCAA athletic team at your University. This research study is being conducted by Ms. Martha Anderson, MS, LAT, ATC, who is a doctoral student at California University of Pennsylvania. This study is in partial fulfillment of the Doctorate of Health Science program requirements. Purpose Through your participation in this study, we hope to gain a more thorough understanding of who collegiate athletes seek out for social support following injury, illness and other life stressors. This study may also assist in developing strategies to improve the available social support for collegiate athletes following injury, illness or other life stressors. Consent & Procedures: You must be 18 years of age to participate. Your participation is voluntary. By finishing the survey and submitting your data implies consent to use the data. Your participation may be discontinued at any time, without penalty and any data will be discarded. The survey consists of three sections. It should take approximately 10 minutes to complete the entire survey. Confidentiality All surveys are stored on the Survey Monkey® website and the CalU Cloud storage with password protection, and only the primary researcher will have access to the data. At the conclusion of the study, the data will be stored on the password protected 117 Cloud for a period of 3 years. At the end of 3 years, the data will be erased. Your participation and results are completely confidential and anonymous. There is no monetary benefit for participating in this study. Risks and Benefits It is highly unlikely you will experience any increased emotions or feelings by completing this survey. However, if you do experience any increased emotions or feelings, there is contact information for free resources available to you that are listed at the end of the survey. You may contact the primary researcher or research advisor with any questions via email or telephone: Primary Researcher: Martha Anderson, MS, LAT, ATC / and9222@calu.edu /484332-6780 Research Advisor: Dr. Linda Meyer, EdD, LAT, ATC / meyer@calu.edu / 814-442-6843 118 * 1. What is your age? Under 18 18 19 20 21 22 23 24 Other (please specify) These questions are pertaining to the SINGLE MOST SIGNIFICANT INJURY you have experienced in the past 12 months. *2. In the past 12 months, which body part was involved in the single most significant injury? I did not have a significant injury. Torso Head Spine Shoulder Hip Elbow Knee Wrist Lower leg Hand Ankle Foot * * * * 3. Please choose which type of head injury you sustained: Concussion Laceration Contusion Fracture 119 * 4. Referring to the body part you listed in the previous question, please choose the type of significant injury you experienced in the past 12 months. Contusion Laceration Strain Sprain Fracture Other Injury (for example: ACL tear, stress fracture, hamstring tendon tear) * 5. In the past 12 months, how many days of lifting, conditioning, practice or games did you miss because of this single most significant injury? Did not miss any days Missed less than a week Missed 1 to 3 weeks Longer than 3 weeks but able to return in the same competitive season Longer than 3 weeks, but unable to return for the remainder of the competitive season Severe injury resulting in permanent disability (loss of limb, quadriplegia) Other (please specify) * 6. Please explain any type of significant illness you experienced in the past 12 months. I did not have any significant illness. Please specify the significant illness you had in the past 12 months. (For example: Mononucleosis, staph infection, flu) 120 * 7. In the past 12 months, how many days of lifting, conditioning, practice or games did you miss because of this single most significant illness? Did not miss any days Missed less than a week Missed 1 to 3 weeks Longer than 3 weeks but able to return in the same competitive season Longer than 3 weeks, but unable to return for the remainder of the competitive season Severe injury resulting in permanent disability (loss of limb, quadriplegia) Other (please specify) * 8. Please identify the single most significant life stressor you have experienced in the last 12 months. Academic and coursework demands Procrastination University environment Finances or money problems Housing or accommodations Transportation issues Mental health issues Physical health issues Family problems Friends problems Relationship problems Romantic relationship problems Work issues Parental expectations Studying and life balance Sexual orientation issues Discrimination Language/cultural issues Other (please explain) * 9. In the past 12 months, think about the single most significant life stressor you experienced. How many days of lifting, conditioning, practice or games did you miss because of this significant life stressor? Did not miss any days Missed less than 1 week Missed 1 to 3 weeks Longer than 3 weeks but able to return in the same competitive season 121 Longer than 3 weeks, but unable to return for the remainder of the competitive season Other (please specify) The following questions refer to your EMOTIONAL WELL-BEING over the past 12 months. Click on the circle which corresponds with your thoughts for each question. * 10. In the last 12 months, how often have you been upset because of something that happened unexpectedly? Never Almost Never Sometimes Fairly Often Very Often * 11. In the last 12 months, how often have you felt that you were unable to control the important things in your life? Never Almost Never Sometimes Fairly Often Very Often * 12. In the last 12 months, how often have you felt nervous and “stressed”? Never Almost Never Sometimes Fairly Often Very Often * 13. In the last 12 months, how often have you felt confident about your ability to handle your personal problems? Never Almost Never Sometimes Fairly Often Very Often * 14. In the last 12 months, how often have you felt that things were going your way? Never Almost Never Sometimes Fairly Often Very Often * 15. In the last 12 months, how often have you found that you could not cope with all the things that you had to do? Never Almost Never Sometimes Fairly Often Very Often 122 * 16. In the last 12 months, how often have you been able to control irritations in your life? Never Almost Never Sometimes Fairly Often Very Often * 17. In the last 12 months, how often have you felt that you were on top of things? Never Almost Never Sometimes Fairly Often Very Often * 18. In the last 12 months, how often have you been angered because of things that were outside of your control? Never Almost Never Sometimes Fairly Often Very Often * 19. In the last 12 months , how often have you felt difficulties were piling up so high that you could not overcome them? Never Almost Never Sometimes Fairly Often Very Often * 20. What is your current year of athletic eligibility? Please choose one answer from the drop down menu below: * 21. What is your primary sport? Please choose an answer from the drop down menu below: 123 * 22. Which of the following best describes your ethnicity? White or Caucasian Black or African American Hispanic or Latino Asian or Asian American American Indian or Alaska Native Native Hawaiian or other Pacific Islander Choose not to answer Other (please specify) * 23. On which sport roster are you an NCAA participant? Men's Sport Women's Sport 124 PERCEPTIONS OF SOCIAL SUPPORT: PART II Multidimensional Scale of Perceived Social Support Read each statement carefully. Indicate how you feel about each statement by clicking the circle which best corresponds with your answer. * 24. There is a special person who is around when I am in need. Very Strongly Disagree Strongly Disagree Mildly Disagree Neutral Mildly Agree Strongly Agree Very Strongly Agree Neutral Mildly Agree Strongly Agree Very Strongly Agree Neutral Mildly Agree Strongly Agree Very Strongly Agree Mildly Disagree Neutral Mildly Agree Strongly Agree Very Strongly Agree Mildly Disagree Neutral Mildly Agree Strongly Agree Very Strongly Agree * 25. My family is willing to help me make decisions. Very Strongly Disagree Strongly Disagree Mildly Disagree * 26. I have friends with whom I can share my joys and sorrows. Very Strongly Disagree Strongly Disagree Mildly Disagree * 27. I can talk about my problems with my family. Very Strongly Disagree Strongly Disagree * 28. My friends really try to help me. Very Strongly Disagree Strongly Disagree * 29. I can count on my friends when things go wrong. Very Strongly Disagree Strongly Disagree Mildly Disagree Neutral Mildly Agree Strongly Agree Very Strongly Agree * 30. I have a special person who is a real source of comfort to me. Very Strongly Disagree Strongly Disagree Mildly Disagree Neutral Mildly Agree Neutral Mildly Agree Strongly Agree Very Strongly Agree * 31. I can talk about my problems with my friends. Very Strongly Disagree Strongly Disagree Mildly Disagree Strongly Agree Very Strongly Agree 125 * 32. I get the emotional help & support I need from my family. Very Strongly Disagree Strongly Disagree Mildly Disagree Neutral Mildly Agree Strongly Agree Very Strongly Agree Strongly Agree Very Strongly Agree * 33. There is a special person in my life who cares about my feelings. Very Strongly Disagree Strongly Disagree Mildly Disagree Neutral Mildly Agree * 34. My family really tries to help me. Very Strongly Disagree Strongly Agree Strongly Disagree Mildly Disagree Neutral Mildly Agree Strongly Agree Very Strongly Agree Very * 35. There is a special person with whom I can share joys and sorrows. Very Strongly Disagree Strongly Disagree Strongly Agree Mildly Disagree Neutral Mildly Agree PERCEPTIONS OF SOCIAL SUPPORT: PART III Athletic Multidimensional Scale of Perceived Social Support Read each statement carefully. Indicate how you feel about each statement by clicking the circle which best corresponds with your answer. * 36. There is an athletic trainer who is around when I am in need. Very Strongly Disagree Strongly Agree Strongly Disagree Mildly Disagree Neutral Mildly Agree Strongly Agree Very * 37. I can talk about my problems with my teammates. Very Strongly Disagree Strongly Disagree Mildly Disagree Strongly Agree Neutral Mildly Agree Strongly Agree Very 126 * 38. My coach is willing to help me make decisions. Very Strongly Disagree Strongly Disagree Agree Mildly Disagree Neutral Mildly Agree Strongly Agree Very Strongly * 39. There is an athletic trainer who cares about my feelings. Very Strongly Disagree Strongly Agree Strongly Disagree Mildly Disagree Neutral Mildly Agree Strongly Agree Very * 40. I have teammates with whom I can share my joys and sorrows. Very Strongly Disagree Strongly Agree Strongly Disagree Mildly Disagree Neutral Mildly Agree Strongly Agree Very Neutral Mildly Agree Strongly Agree Very Mildly Agree Strongly Agree Very * 41. I can talk about my problems with my coaches. Very Strongly Disagree Strongly Agree Strongly Disagree Mildly Disagree * 42. I can count on my teammates when things go wrong. Very Strongly Disagree Strongly Agree Strongly Disagree Mildly Disagree Neutral * 43. My teammates really try to help me. Very Strongly Disagree Agree Strongly Disagree Mildly Disagree Neutral Mildly Agree Strongly Agree Very Strongly Strongly Agree Very Strongly * 44. I have an athletic trainer who is a real source of comfort to me. Very Strongly Disagree Agree Strongly Disagree Mildly Disagree Neutral Mildly Agree 127 * 45. I get the emotional help and support I need from my coaches. Very Strongly Disagree Agree Strongly Disagree Mildly Disagree Neutral Mildly Agree Strongly Agree Very Strongly Mildly Agree Strongly Agree Very Strongly * 46. My coaches really try to help me. Very Strongly Disagree Strongly Disagree Mildly DIsagree Neutral Agree * 47. There is an athletic trainer with whom I can share my joys and sorrows. Very Strongly Disagree Strongly Disagree Strongly Agree Mildly Disagree Neutral Mildly Agree Strongly Agree Very Thank you for participating! Please click the DONE button at the bottom of the page to finish! If you or anyone you know are having difficulty dealing with any emotions or feelings you or they may be experiencing, please utilize any of the free resource providers listed below. FREE RESOURCES: Service Access Management (SAM): Available 24/7 877236-4600 Are you okay? (RUOK): Available 24/7 Text RUOK to 7865 OR contact your athletic trainer, local mental health provider, campus counseling center, if available, or call 911 128 Appendix C2 Introductory Letter to Students 129 Dear PSAC Athlete, My name is Martha Anderson, and currently a doctoral student at California University of PA and an athletic trainer at Kutztown University. I am conducting a research study on who collegiate athletes seek out for social support following injury, illness, or other stressors, and you could really help me out by volunteering to participate in my study. You must be 18 years of age or older to participate in the study. I am asking for participation from all team rostered PSAC universities’ athletes because you represent one of the largest conferences in all of Division II athletics, and you are a unique group of athletes. Participation is completely voluntary, confidential, and anonymous. The survey should take approximately 10 minutes to complete. If you would like to participate in the study, please follow this link or scan the QR Code: https://www.surveymonkey.com/r/Z8JYZKV If you have any questions, you may reach me at 484-646-4284 or via email at and9222@calu.edu Thank you so much for your willingness to participate in this study so that we may better understand the important role social support plays following injury, illness, or other stressors. It is greatly appreciated. Again, thank you for your participation, Martha Anderson, ABD, LAT, ATC, CES, PES 130 Appendix C3 Athletic Director and Athletic Trainer Contact Information 131 University Bloomsburg California U. of PA Clarion East Stroudsburg Edinboro Gannon Indiana U. of PA Kutztown Lock Haven Mansfield Mercyhurst Millersville Univ. of Pitt-Johnstown Seton Hill Shepherd Shippensburg Slippery Rock West Chester University Bloomsburg California U. of PA Clarion East Stroudsburg Edinboro Gannon Indiana U. of PA Kutztown Lock Haven Mansfield Administrator Dr. Michael McFarland Dr. Karen Hjerpe Dr. Wendy Snodgrass Dr. Gary Gray Dr. Katherine Robbins Lisa Goddard McGuirk Todd Garzarelli Greg Bamberger Dr. Tom Gioglio Peggy Carl Bradley Davis Miles Gallagher Pat Pecora Chris Snyder Chauncey Winbush Jeff Michaels Paul Lueken Terry Beattie Athletic Trainer Email address mcfarland@bloom.edu hjerpe@calu.edu wsnodgrass@clarion.edu ggray2@esu.edu krobbins@edinboro.edu 570-389-4050 724-938-4167 814-393-1997 570-422-3689 814-871-7664 mcguirk@gannon.edu tgarzare@iup.edu bamberger@kutztown.edu tmg252@lockhave.edu pcarl@mansfield.edu bdavis@merchurst.edu mgallagher@millersville.edu ppecora@pitt.edu csnyder@setonhill.edu cwinbush@shepherd.edu jamich@ship.edu paul.lueken@sru.edu tbeattie@wcupa.edu 814-871-7664 724-357-4295 610-683-4096 570-484-2102 570-662-4636 814-824-3101 717-871-7694 814-269-2000 724-830-1895 304-876-5155 717-477-1711 724-738-2767 610-436-3555 Email Address alarsen@bloomu.edu zema@calu.edu jthornton@clarion.edu cshotwell@esu.edu ghanna@edinboro.edu roth031@gannon.edu jbaum@iup.edu manderso@kutztown.edu yingram@lockhaven.edu lzaparzy@mansfield.edu Millersville Univ. of Pitt-Johnstown Seton Hill Shepherd Allen Larsen Scott Zema Jim Thornton Colleen Shotwell Gary Hannah Andrea Roth Jessica Baum-Mehus Martha Anderson Yvette Ingram Laurie Zaprazynski Andy SimonWambach Wendy WheelerDetrich Elissa Till Peggy Fillinger Shatora Lane Shippensburg Slippery Rock West Chester Miranda Fisher Molly Parsons Lindsay Keenan mfisher@ship.edu molly.parsons@sru.edu lmcguire@wcupa.edu Mercyhurst Phone Number Phone number 570-389-4369 724-884-5104 814-393-2456 570-422-3165 814-732-1860 814-871-5300 724-357-2756 484-332-6780 570-484-3098 570-662-4467 asimonwambach@mercyhurst.edu 814-824-2259 wendy.wheelerdietrich@millersville.edu till@pitt.edu mfillinger@setonhill.edu slane@shepherd.edu 717-871-4227 814-824-2259 724-522-4324 304-876-5348 717-477-1749 x3 724-738-4240 610-436-2753 132 Appendix C4 Email to Athletic Administrators 133 _____________________________________________________________________________________ Martha Anderson, MS, LAT, ATC Phone: 484-646-4284 Fax: 610-683-4664 and9222@calu.edu August 28, 2020 Dear Athletic Administrators, I am pursuing my doctoral degree in California University of Pennsylvania’s Health Science and Exercise Leadership program, and I am also an athletic trainer for Kutztown University. I am asking for your approval and confirmation to allow the athletes from your university to participate in a study. I am investigating who athletes perceive as providing them with social support following injury or response to other stressors identified life stressors - friends, family, significant others, teammates, coaches, or athletic trainers. I will be working with one of your athletic trainers for student-athlete recruitment for participation in this study. Their responsibilities are to display the posters and flyers with the QR code and weblink to the survey in the athletic training room, team locker rooms, and weight room. They will also be encouraged to share the information electronically via any of the team communication methods your student-athletes may use to communicate team information. Athletes who choose to participate will complete an electronic survey that will take less than 10 minutes to complete. If the athlete chooses, they may exit the study at any time, and their data will be discarded. Participation will be voluntary and anonymous. There is no cost or remuneration associated with participation, and there is minimal risk to the athletes. The minimal risk may be an increase in emotions after recalling a recent injury. There will be phone numbers of available free resources at the end of the survey of for individuals who feel they may need assistance as a result of experiencing these emotions. I have received approval from California University of Pennsylvania’s Institutional Review Board to perform the study from July 20, 2020 to July 19, 2021. Please respond to me via email for confirmation or denial of your university’s athletic department participation in this study. The anticipated dates to make the electronic survey available to the athletes is August 3rd thru August 24th, 2020. Again, I am asking you to either email or call me to confirm your institution’s participation in this study no later than July 31, 2020. I look forward to hearing from you.If there are any questions, I can be reached via Email: and9222@calu.edu or by phone: 484-332-6780. Sincerely, Ms. Martha J. Anderson, MS, LAT, ATC Dr. Linda Meyer, California University of Pennsylvania Research Advisor Email: meyer@calu.edu or Office Phone: 814-442-6843 134 Appendix C5 Email to the Designated Contact Athletic Trainers 135 _____________________________________________________________________________________ Martha Anderson, MS, LAT, ATC Phone: 484-646-4284 and9222@calu.edu Fax: 610-683-4664 Dear Athletic Trainers, I am a doctoral student in the California University of Pennsylvania’s Health Science and Exercise Leadership program and an athletic trainer at Kutztown University. I am investigating who athletes perceive as providing them with social support following injury or response to other stressors-their friends, family, significant others, teammates, coaches, or athletic trainers. I have received Cal U’s IRB approval from July 20, 2020, through July 19, 2020, and approval from your Athletic Director to perform the survey research on your campus. Your administrative assistance will be paramount in the recruitment of volunteer subjects. I will be providing posters and flyers with QR codes to be posted in your athletic training room(s), team locker rooms, weight rooms, and anywhere else which may be visible to your athletes. You may also post or distribute the QR Code through team communications, social media or via studentathlete email. The research consists of one survey with three brief sections, which can be completed in about 10 minutes. It will consist of demographic questions, Perceived Stress Scale (PSS) the Multidimensional Scale of Perceived Social Support (MSPSS), and an adaption of the MSPSS, the Athletic Multidimensional Scale of Perceived Social Support (AMSPSS). Surveys will be delivered via a QR Code that will be linked to the Survey Monkey® survey. There is no cost or remuneration for participation. There is minimal risk to the student-athletes. The minimal risk may be an increase in emotions after recalling a recent athletic injury. There will be phone numbers of available free resources for assistance organizations. Participation is confidential and anonymous. If the athlete chooses, they may exit the study at any time, and their data will be discarded. We are hoping to get as much participation as possible in order to improve the strength of the study. The posters and QR Codes should be distributed tentatively from August 3, 2020, through August 24, 2020. Should you require more materials, please contact me, and I will mail them to you. If there are any questions or difficulties in accessing the study, please contact me directly. I have included copies of the separate surveys so you are aware of the questions that will be asked. I am asking that you do not take the actual survey, as this will interfere with the data collection. Your participation is truly appreciated, Martha Anderson, MS, LAT, ATC, Primary Researcher Office: 484-646-4284 Cell: 484-332-6780 Dr. Linda Meyer, EdD, LAT, ATC, California University of Pennsylvania Research Advisor Office Phone: 814-442-6846 / Email: meyer@calu.edu Research Committee Members: Dr. Tom West PhD, LAT, ATC (west_t@calu.edu) Dr. Yvette Ingram, PhD, LAT, ATC (ingram@lockhaven.edu) Dr. Ellen West, EdD, LAT, ATC (west_e@calu.edu) 136 PERCEIVED STRESS SCALE: The questions in this scale ask you about your feelings and thoughts during the last month. In each case, you will be asked to indicate by circling how often you felt or thought a certain way. Name _______________ Date ______________ Age _______ Gender (Circle): M F Other 0= Never 1 = Almost Never 2 = Sometimes 3 = Fairly Often 4 = Very Often In the last 12 months, how often have you been upset because of something that happened unexpectedly? 0 1 2 3 4 In the last 12 months, how often have you felt that you were unable to control the important things in your life? 0 1 2 3 4 In the last 12 months, how often have you felt nervous and “stressed”? 0 1 2 3 4 In the last month, how often have you felt confident about your ability to handle your personal problems? 0 1 2 3 4 In the last 12 months, how often have you felt that things were going your way? 0 1 2 3 4 In the last 12 months, how often have you found that you could not cope with all the things that you had to do? 0 1 2 3 4 In the last 12 months, how often have you been able to control irritations in your life? 0 1 2 3 4 In the last 12 months, how often have you felt that you were on top of things? 0 1 2 3 4 In the last 12 months, how often have you been angered because of things that were outside of your control? 0 1 2 3 4 In the last 12 months, how often have you felt difficulties were piling up so high that you could not overcome them? 0 1 2 3 4 137 Multidimensional Scale of Perceived Social Support Instructions: We are interested in how you feel about the following statements. Read each statement carefully. Indicate how you feel about each statement. Circle the “1” if you Very Strongly Disagree, Circle the “2” if you Strongly Disagree, Circle the “3” if you Mildly Disagree, Circle the “4” if you are Neutral, Circle the “5” if you Mildly Agree, Circle the “6” if you Strongly Agree, Circle the “7” if you Very Strongly Agree 1. There is a special person who is around when I am in need. 1234567 2. There is a special person with whom I can share joys and sorrows. 1234567 3. My family really tries to help me. 1234567 4.I get the emotional help & support I need from my family. 1234567 5. I have a special person who is a real source of comfort to me. 1234567 6 My friends really try to help me. 1234567 7. I can count on my friends when things go wrong. 1234567 8. I can talk about my problems with my family. 1234567 9. I have friends with whom I can share my joys and sorrows. 1234567 10. There is a special person in my life who cares about my feelings. 1234567 11. My family is willing to help me make decisions. 1234567 12. I can talk about my problems with my friends. 1234567 138 Athletic Multidimensional Scale of Perceived Social Support Instructions: We are interested in how you feel about the following statements. Read each statement carefully. Indicate how you feel about each statement. Circle the “1” if you Very Strongly Disagree, Circle the “2” if you Strongly Disagree, Circle the “3” if you Mildly Disagree, Circle the “4” if you are Neutral, Circle the “5” if you Mildly Agree, Circle the “6” if you Strongly Agree, Circle the “7” if you Very Strongly Agree 1. There is an athletic trainer who is around when I am in need. 1234567 2. There is a athletic trainer with whom I can share joys and sorrows. 1234567 3. My coach really tries to help me. 1234567 4.I get the emotional help & support I need from my coach. 1234567 5. I have an athletic trainer who is a real source of comfort to me. 1234567 6 My teammates really try to help me. 1234567 7. I can count on my teammates when things go wrong. 1234567 8. I can talk about my problems with my coach. 1234567 9. I have teammates with whom I can share my joys and sorrows. 1234567 10. There is an athletic trainer in my life who cares about my feelings. 1234567 11. My coach is willing to help me make decisions. 1234567 12. I can talk about my problems with my teammates. 1234567 139 University Stress Scale How often have each of the following caused you stress in the past few weeks. If any are not applicable to you, tick Not at all. Not at all 0 Sometimes 1 Frequently 2 Constantly 3 * * * * * * * * * * * * * * * * * * * * * Academic/coursework demands Procrastination University/college environment Finances and money problems Housing/accommodation Transport Mental health problems Physical health problems Parenting issues Childcare Family relationships Friendships Romantic relationships Relationship break-down Work Parental expectations Study/life balance Discrimination 19. Sexual orientation issues Language/cultural issues Other demands SCORING USS Total = sum of items 1– 21 Range = 0 to 63 REFERENCES Measure Stallman, H. M. (2008). University Stress Scale. Brisbane: Queensland University of Technology. Psychometric Properties Stallman, H. M., & Hurst, C. P. (2016). The University Stress Scale: Measuring Domains and Extent of Stress in University Students. Australian Psychologist, 51(2), 128-134. doi:10.1111/ap.12127 140 Appendix C6 Quick Response Code 141 STUDENT ATHLETES: Would you like to help yourself, your teammates, coaches and athletic trainers? We are looking for NCAA athletes to volunteer to participate in a study that is examining who athletes turn to for social support. The study takes less than 10 minutes to complete. If you’re interested, scan the code below and it will take you to the survey. OR if you are on your computer, click on the link: https://www.surveymonkey.com/r/2020SocialSupport2 (You must be 18 or older to participate) 142 Appendix C7 Thank you Email to Athletic Trainers 143 _____________________________________________________________________________________ Martha Anderson, MS, LAT, ATC Phone: 484-646-4284 and9222@calu.edu Fax: 610-683-4664 Ms. Martha Anderson, MS, LAT, ATC 228 Sycamore Road West Reading, PA 19611 Dear Athletic Trainers, I would like to offer my sincerest thanks and gratitude for your participation and administrative assistance in my dissertation study. It is my hope that with the addition of a sport-specific instrument to measure perceived social support, members of the athletic community will have more knowledge about the importance of their support needed by those student-athletes who have sustained an injury. Hopefully, we can gain insight into this critical aspect of athletic injury recovery for the athletes for whom we provide services. Should you have any questions, please contact me via phone or email. Thank you again for your participation and assistance, Martha Anderson, MS, LAT, ATC (o) 484-646-4284 (c) 484-332-6780 Email: and9222@calu.edu 144 Appendix C8 IRB Review Request 145 Proposal Number 19-067______ Date Received 8/25/20 IRB Review Request Institutional Review Board (IRB) approval is required before beginning any research and/or data collection involving human subjects Submit this form to instreviewboard@calu.edu or Campus Box #109 Project Title: Identifying collegiate athletes’ social support networks following injury, illness and response to other identified life stressors. Researcher/Project Director Martha J. Anderson Phone # 484-332-6780 E-mail Address and9222@calu.edu Faculty Sponsor (if researcher is a student) Department Dr. Linda Meyer, EdD, LAT, ATC Exercise Science and Sports Studies Anticipated Project Dates July 20, 2020 to July 19, 2021 Sponsoring Agent (if applicable) Project to be Conducted at Project Purpose: Pennsylvania State Athletic Conference Universities Thesis Research Class Project X Other: Dissertation Keep a copy of this form for your records. Required IRB Training All researchers must complete an approved Human Participants Protection training course. The training requirement can be satisfied by completing the CITI (Collaborative Institutional Training Initiative) online course at http://www.citiprogram.org New users should affiliate with “California University of Pennsylvania” and select the “All Researchers Applying for IRB Approval”course option. A copy of your certification of training must be attached to this IRB Protocol. If you have completed the training within the past 3 years and have already provided documentation to the IRB, please provide the following: 146 Previous Project Title Date of Previous Project IRB Approval Provide an overview of your project-proposal describing what you plan to do and how you will go about doing it. Include any hypothesis(es)or research questions that might be involved and explain how the information you gather will be analyzed. All items in the Review Request Checklist, (see below) must be addressed. 1. Please attach a typed, detailed summary of your project and complete items 2-6. The aim of the present study seeks to identify those individuals whom NCAA collegiate athletes from the Pennsylvania State Athletic Conference (PSAC) universities seek out for social support following injury, illness, or other identified life stressors. There are two hypotheses which are driving this research study. First, there will be greater amounts of perceived social support from teammates, coaches, and athletic trainers than from friends, family, and significant others, dependent upon injury status (injured vs. non-injured), illness (illness vs. no illness), and other identified life stressors. Second, differences in age, gender, ethnicity, sport, and year of athletic eligibility will influence the perception of social support from teammates, coaches, athletic trainers, friends, family and significant others. The participants of this study will represent a sample of convenience of male and female student-athletes, 18 years of age or older. These subjects will be current athletes from the 18 universities which comprise the PSAC. The research design for this study is a non-experimental group comparison. Independent variables are the college athletes’ injury history over the previous 12 months (injury or no injury), illness over the previous 12 months (illness or no illness), and perceived life stress history over the previous 12 months (stressor or no stressor) and the specific demographics of gender, ethnicity, sport and year of athletic eligibility. Dependent variables will be the athletes’ perception of social support from teammates, coaches, athletic trainers, friends, family, and significant others. Following California University IRB approval, Athletic Administrators (AA) from each PSAC University will be contacted via email and/or telephone, in order to obtain consent for their university’s participation in the study. Following AA consent, the designated contact athletic trainer at each institution will be contacted by the primary researcher via email and/or telephone. Communication with the athletic trainer will include the purpose of the study, study design, methods and a copy of the instruments which will be used in the study, which will be used solely for informational purposes. Both hypotheses will be tested through the administration of an online survey accessed from the Survey Monkey® website. All participation will be voluntary, confidential, and anonymous. Due to the potential of COVID-19 influencing on-campus 147 operations, there will be two scenarios for disseminating the information to the participants. Scenario I, is that athletes are on campus, volunteer athlete participants will be asked to participate through the use of informational posters which will contain a Quick Response code (QR Code) and a Post-It Note® type pad which has the QR code and hyperlink to the survey on each page of the pad. Athletes may take that information with them. In addition, the information may be delivered via any source of electronic team communication (text message, twitter, etc.) used by each university to communicate with athletes. Scenario II is that athletes have not returned to campus, so volunteer athlete participants will be sent the hyperlink via email or any other electronic means of communication that institution is using to communicate with its athletes. The survey consists of three sections: demographic questions and the Perceived Stress Scale (PSS), the Multidimensional Scale of Perceived Social Support (MSPSS), and the Athletic Multidimensional Scale of Perceived Social Support (AMSPSS). There are up to 21 questions on the demographic portion, which is dependent upon whether or not the participant had an injury, illness or stressor, or a combination of the three; and the level of stress using the 10 question Perceived Stress Scale (PSS). The second and third portion of the survey are the 12 questions on the MSPSS and the 12 questions on the AMSPSS, respectively. The PSS, MSPSS, and AMSPSS are rated using a Likert scale. The entire survey should take approximately 10 minutes to complete. The informed consent letter can be seen in Appendix A7, page 25. 2. Section 46.11 of the Federal Regulations state that research proposals involving human subjects must satisfy certain requirements before the IRB can grant approval. You should describe in detail how the following requirements will be satisfied. Be sure to address each area separately. (text boxes will expand to fit responses) a. How will you ensure that any risks to subjects are minimized? If there are potential risks, describe what will be done to minimize these risks. If there are risks, describe why the risks to participants are reasonable in relation to the anticipated benefits. All participants will be made aware of the possible minimal risks of experiencing an increase in emotional and/or psychological responses while answering the questions in the survey This statement is made in the informed consent letter. There will be contact information for free resources to assist the participants should they have increased emotional and/or psychological responses. This information will be available and accessible at the end of the study. These minimal risks are reasonable due to the fact the subjects are simply recalling feelings and not experiencing the stressor for the first time and will therefore be less likely to experience a stressful event when completing the survey. The benefits of this study are being able to identify those individuals and resources athletes are more or less likely to utilize in times of experiencing injury, illness or stress. With this knowledge, the individuals who are likely to have contact with these athletes may be better prepared to anticipate the need to provide support. Gaining this information 148 may in fact help minimize the stress athletes may experience in the future and, and thus outweighing the potential harm of these minimal risks. b. How will you ensure that the selection of subjects is equitable? Take into account your purpose(s). Be sure you address research problems involving vulnerable populations such as children, prisoners, pregnant women, mentally disabled persons, and economically or educationally disadvantaged persons. If this is an in-class project describe how you will minimize the possibility that students will feel coerced. Any athletes who are not 18 or older will be excluded from the study. This will be stated on the posters advertising the study. Further, it is the first question on the survey. If the student answers that they are not 18, the subject will be directed to the end of the survey. There is equal opportunity for both male and female athletes to participate, as no NCAA varsity sports sponsored by the Pennsylvania State Athletic Conference (PSAC) have been excluded from the study. Posters and flyers for participation in the study will be posted where all athletes will have the same opportunity to respond to the surveys. This will include the coeducational athletic training rooms, weight rooms and individual team locker areas. Campus emails or other means of electronic communication (Text message, GroupMe, etc.) will be used to contact the athletic teams if the students are not on campus. The way in which the athletes will receive the study information will be at the discretion of the designated contact athletic trainer. Participation is completely voluntary and there will be no coercion to participate. c. How will you obtain informed consent from each participant or the subject’s legally authorized representative and ensure that all consent forms are appropriately documented? Be sure to attach a copy of your consent form to the project summary. There is an informed consent letter which needs to be reviewed prior to beginning the survey. By using an electronic questionnaire format, consent is implied if they continue to participate in the study. By continuing to the end of the study and submitting their data, the participants are granting implied consent to use their data. This statement is also in the informed consent letter. d. Show that the research plan makes provisions to monitor the data collected to ensure the safety of all subjects. This includes the privacy of subjects’ responses and provisions for maintaining the security and confidentiality of the data. All data will be password protected on the Survey Monkey® website for one year after data collection and the Cal U Cloud for three years after data collection. Only the primary researcher will have the password and thus have the only access to the data. There will be no unique identifiers assigned to the participants and none of their vital information, such as name, date of birth, social security number will be requested. 3. Check the appropriate box(es) that describe the subjects you plan to target. 149 Adult volunteers Mentally Disabled People [X] CAL University Students Economically Disadvantaged People [X] Other Students Educationally Disadvantaged People Prisoners Fetuses or fetal material Pregnant Women Children Under 18 Physically Handicapped People Neonates 4. Is remuneration involved in your project? 5. Is this project part of a grant? information: Yes or [X] No. If yes, Explain here. Yes or [X] No If yes, provide the following Title of the Grant Proposal Name of the Funding Agency Dates of the Project Period 6. Does your project involve the debriefing of those who participated? Yes or [X] No If Yes, explain the debriefing process here. 7. If your project involves a questionnaire or interview, ensure that it meets the requirements indicated in the Survey/Interview/Questionnaire checklist. 150 California University of Pennsylvania Institutional Review Board Survey/Interview/Questionnaire Consent Checklist (v021209) This form MUST accompany all IRB review requests Does your research involve ONLY a survey, interview or questionnaire? YES—Complete this form NO—You MUST complete the “Informed Consent Checklist”—skip the remainder of this form Does your survey/interview/questionnaire cover letter or explanatory statement include: [X] (1) Statement about the general nature of the survey and how the data will be used? [X] (2) Statement as to who the primary researcher is, including name, phone, and email address? [X] (3) FOR ALL STUDENTS: Is the faculty advisor’s name and contact information provided? [X] (4) Statement that participation is voluntary? [X] (5) Statement that participation may be discontinued at any time without penalty and all data discarded? [X] (6) Statement that the results are confidential? [X] (7) Statement that results are anonymous? [X] (8) Statement as to level of risk anticipated or that minimal risk is anticipated? (NOTE: If more than minimal risk is anticipated, a full consent form is required—and the Informed Consent Checklist must be completed) [X] (9) Statement that returning the survey is an indication of consent to use the data? [X] (10) Who to contact regarding the project and how to contact this person? [X] (11) Statement as to where the results will be housed and how maintained? (unless otherwise approved by the IRB, must be a secure location on University premises) [X] (12) Is there text equivalent to: “Approved by the California University of Pennsylvania Institutional Review Board. This approval is effective nn/nn/nn and expires mm/mm/mm”? (the actual dates will be specified in the approval notice from the IRB)? [X] (13) FOR ELECTRONIC/WEBSITE SURVEYS: Does the text of the cover letter or 151 explanatory statement appear before any data is requested from the participant? [X] (14) FOR ELECTONIC/WEBSITE SURVEYS: Can the participant discontinue participation at any point in the process and all data is immediately discarded? 152 California University of Pennsylvania Institutional Review Board Review Request Checklist (v021209) This form MUST accompany all IRB review requests. Unless otherwise specified, ALL items must be present in your review request. Have you: [X] (1.0) FOR ALL STUDIES: Completed ALL items on the Review Request Form? Pay particular attention to: [X] (1.1) Names and email addresses of all investigators [X] (1.1.1) FOR ALL STUDENTS: use only your CalU email address) [X] (1.1.2) FOR ALL STUDENTS: Name and email address of your faculty research advisor [X] (1.2) Project dates (must be in the future—no studies will be approved which have already begun or scheduled to begin before final IRB approval— NO EXCEPTIONS) [X] (1.3) Answered completely and in detail, the questions in items 2a through 2d? [X] 2a: NOTE: No studies can have zero risk; the lowest risk is “minimal risk”. If more than minimal risk is involved, you MUST: [_] i. Delineate all anticipated risks in detail [_] ii. Explain in detail how these risks will be minimized [_] iii. Detail the procedures for dealing with adverse outcomes due to these risks. [_] iv. Cite peer reviewed references in support of your explanation. [X] 2b. Complete all items. [X] 2c. Describe informed consent procedures in detail. [X] 2d. NOTE: to maintain security and confidentiality of data, all study records must be housed in a secure (locked) location ON UNIVERSITY PREMISES. The actual location (department, office, etc.) must be specified in your explanation and be listed on any consent forms or cover letters. [X] (1.4) Checked all appropriate boxes in Section 3? If participants under the age of 18 years are to be included (regardless of what the study involves) you MUST: [_] (1.4.1) Obtain informed consent from the parent or guardian— consent forms must be written so that it is clear that the parent/guardian is giving permission for their child to participate. [_] (1.4.2) Document how you will obtain assent from the child— This must be done in an age-appropriate manner. Regardless of whether the parent/guardian has given permission, a child is completely free to refuse to participate, so the investigator must document how the child indicated agreement to participate (“assent”). [_] (1.5) Included all grant information in section 5? 153 [X] (1.6) Included ALL signatures? [_] (2.0) FOR STUDIES INVOLVING MORE THAN JUST SURVEYS, INTERVIEWS, OR QUESTIONNAIRES: [_] (2.1) Attached a copy of all consent form(s)? [_] (2.2) FOR STUDIES INVOLVING INDIVIDUALS LESS THAN 18 YEARS OF AGE: attached a copy of all assent forms (if such a form is used)? [_] (2.3) Completed and attached a copy of the Consent Form Checklist? (as appropriate—see that checklist for instructions) [X] (3.0) FOR STUDIES INVOLVING ONLY SURVEYS, INTERVIEWS, OR QUESTIONNAIRES: [X] (3.1) Attached a copy of the cover letter/information sheet? [X] (3.2) Completed and attached a copy of the Survey/Interview/Questionnaire Consent Checklist? (see that checklist for instructions) [X] (3.3) Attached a copy of the actual survey, interview, or questionnaire questions in their final form? [X] (4.0) FOR ALL STUDENTS: Has your faculty research advisor: [X] (4.1) Thoroughly reviewed and approved your study? [X] (4.2) Thoroughly reviewed and approved your IRB paperwork? including: [X] (4.2.1) Review request form, [X] (4.2.2) All consent forms, (if used) [_] (4.2.3) All assent forms (if used) [X] (4.2.4) All Survey/Interview/Questionnaire cover letters (if used) [X] (4.2.5) All checklists [X] (4.3) IMPORTANT NOTE: Your advisor’s signature on the review request form indicates that they have thoroughly reviewed your proposal and verified that it meets all IRB and University requirements. [X] (5.0) Have you retained a copy of all submitted documentation for your records? 154 Project Director’s Certification Program Involving HUMAN SUBJECTS The proposed investigation involves the use of human subjects and I am submitting the complete application form and project description to the Institutional Review Board for Research Involving Human Subjects. I understand that Institutional Review Board (IRB) approval is required before beginning any research and/or data collection involving human subjects. If the Board grants approval of this application, I agree to: 1. Abide by any conditions or changes in the project required by the Board. 2. Report to the Board any change in the research plan that affects the method of using human subjects before such change is instituted. 3. Report to the Board any problems that arise in connection with the use of human subjects. 4. Seek advice of the Board whenever I believe such advice is necessary or would be helpful. 5. Secure the informed, written consent of all human subjects participating in the project. 6. Cooperate with the Board in its effort to provide a continuing review after investigations have been initiated. I have reviewed the Federal and State regulations concerning the use of human subjects in research and training programs and the guidelines. I agree to abide by the regulations and guidelines aforementioned and will adhere to policies and procedures described in my application. I understand that changes to the research must be approved by the IRB before they are implemented. Professional (Faculty/Staff) Research Project Director’s Signature Student or Class Research MS, LAT, ATC Student Researcher’s Signature Supervising Faculty Member’s Signature ACTION OF REVIEW BOARD (IRB use only) The Institutional Review Board for Research Involving Human Subjects has reviewed this application to ascertain whether or not the proposed project: 1. 2. 3. 4. 5. provides adequate safeguards of the rights and welfare of human subjects involved in the investigations; uses appropriate methods to obtain informed, written consent; indicates that the potential benefits of the investigation substantially outweigh the risk involved. provides adequate debriefing of human participants. provides adequate follow-up services to participants who may have incurred physical, mental, or emotional harm. Approved[_________________________________] ___________________________________________ Chairperson, Institutional Review Board Disapproved Date 155 Institutional Review Board California University of Pennsylvania Morgan Hall, 310 250 University Avenue California, PA 15419 instreviewboard@calu.edu Melissa Sovak, Ph.D. Dear Martha, Please consider this email as official notification that your proposal titled “Identifying Collegiate Athletes’ Social Support Networks Following Injury, Illness, and Response to Other Identified Life Stressors” (Proposal #19-067) has been approved by the California University of Pennsylvania Institutional Review Board as submitted. The effective date of approval is 7/20/20 and the expiration date is 7/19/21. 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 156 (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 7/19/21 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, Melissa Sovak, PhD. Chair, Institutional Review Board 157 Appendix C9 References 158 References Abgarov, A., Jeffery-Tosoni, S., Baker, J., & Fraser-Thomas, J. (2012). Understanding social support throughout the injury process among interuniversity swimmers. 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Journal of personality assessment, 52(1), 30-41. https://doi.org/10.1207/s15327752jpa5201_2 185 Appendix C10 Supporting Materials 186 MARTHA J ANDERSON, MS, LAT, ATC 228 Sycamore Road, West Reading, PA 19611 | 484-646-4284 | manderso@kutztown.edu EDUCATION California University of Pennsylvania Doctor in Health Science & Exercise Leadership California University of Pennsylvania Master of Science in Intercollegiate Athletic Administration 2015 Presidential Scholar California University of Pennsylvania Post Master’s Certificate in Sport Psychology 2017- Present 2014-2015 2011 California University of Pennsylvania Post Master’s Certificate in Wellness and Fitness Personal Trainer 2009 California University of Pennsylvania Post Master’s Certificate in Rehabilitation Science Performance Enhancement Specialist 2008 California University Post Master’s Certificate in Rehabilitation Science07 Corrective Exercise Specialist University of Pittsburgh Master of Science in Athletic Training and Exercise Physiology Graduate Project: The Effects of a Plyometric Exercise Program on the Upper Extremity Proprioception of Collegiate Female Volleyball Players Kutztown University of Pennsylvania Additional 18 Graduate Level Credits Bachelor of Science in Art Education Instructional I Certificate 1994-1996 1992-1994 1987-1991 West Chester University Summer Athletic Training Program 1993 Lehigh County Community College Anatomy and Physiology Prerequisites 1991-1992 PROFESSIONAL EXPERIENCE Kutztown University of Pennsylvania Faculty Athletic Trainer Promoted to Assistant Professor Tenured 2004-Present 2009 2010 Westminster College/Sharon Regional Health System Clinical Outreach Staff Athletic Trainer 1998-2004 West Snyder High School/Lewistown Hospital Clinical and Clinical Outreach Staff Athletic Trainer 1996-1998 Carlow College/University of Pittsburgh Head Athletic Trainer/Graduate Assistantship 1995-1996 187 PROFESSIONAL CERTIFICATIONS Athletic Training Certification National Athletic Trainers’ Association Athletic Training State License Commonwealth of Pennsylvania Member Number 099402509 License Number RT001363A American Heart Association Basic Life Support Provider CPR/First Aid/AED 2015-Present American Red Cross Community First Aid/CPR/AED Instructor Mercer County, PA Chapter Berks County, PA Chapter 2002-2006 2004 – 2014 American Red Cross Professional Rescuer CPR/First Aid Certification 2005 – 2014 Ténica Gavilán PTB® Certified Instrument Assisted Soft Tissue Mobilization Technique 2013 National Academy of Sports Medicine Corrective Exercise Specialist Performance Enhancement Specialist Certified Personal Trainer Credential # 189443 Credential # 231945 Credential # 1365187 PROFESSIONAL AFFILIATIONS Eastern Athletic Trainer’s Society Pennsylvania Athletic Trainer’s Society State Emergency Registry of Volunteers in Pennsylvania 1994–Present 1994 – Present 2011 – Present PROFESSIONAL ACCOMPLISHMENTS National Athletic Trainer’s Association NATA Convention abstract proposal reviewer 2015-Present Pennsylvania State System of Higher Education Peer Reviewer for Grant Proposals 2012 - Present Kutztown University of Pennsylvania Developed Intercollegiate Athletics Mental Health Policy and Procedures and Emergency Action Plan Concussion Study with Chestnut Hill College Preceptor for Athletic Training Students West Chester University East Stroudsburg University Alvernia University Temporary Exercise Physiology Professor Developed Department of Athletic Faculty Procedures for Promotion and Tenure Guidelines Kutztown University Health and Wellness Expo Presenter First Aid for Common Weekend Warrior Injuries Stretching Philosophy and Techniques Body Fat Analysis CONTINUING PROFESSIONAL EDUCATION NATA Virtual Symposium The 2018 Micheli Lecture: Psychology of Sport Injury & Rehabilitation Boston, MA Annual Central Pennsylvania Sports Medicine Symposium Hershey, PA PROFESSIONAL CONTINUING EDUCATION CONTINUED 2018 2018 2019 2014 – Present 2015 – Present 2012 2012 2010-2014 2020 2018 2020, 2018 188 Penn Medicine Sports Performance Symposium Philadelphia, PA Rothman Institute 13th Annual Sports Medicine Symposium PSAC Team Physician and Athletic Trainer Meeting Lock Haven, PA PSAC Mental Health Symposium Lock Haven, PA NCAA Mental Health Symposium Lock Haven, PA Understanding Evidence-Based Practice and Patient Reported Outcomes Allentown, PA Eastern Athletic Trainer’s Association 66th Annual Convention Mashantucket, CT COMMITTEE INVOLVEMENT Kutztown University Wellness Committee General Education Assessment Committee Rater Institution Review Board Committee Head Lacrosse Coach Search Committee Member Commission on the Status of Women Honorary Doctorate Committee, Chair Honorary Doctorate Committee ChairNet, Secretary Commission on Human Diversity University Calendar Committee Certified Athletic Trainer Search Committee, Chair Associate Athletic Director Search Committee CAS: Sports Medicine Services Program Review Committee Kutztown University, Department of Athletic Faculty Department Promotion Committee Chair Department Chairperson Acting Department Chairperson for Promotion Applicants Performance Evaluation Team, Annual Reviews for Athletic Department Faculty SPECIAL EVENT EXPERIENCE Kutztown University NCAA Field Hockey National Championship Tournament PSAC Indoor Track and Field Championships PSAC Outdoor Track and Field Championships PSAC Field Hockey Championships PSAC Outdoor Track and Field Championships NCAA Division II Regional Men’s Basketball Tournament PSAC Men’s Basketball Conference Championship PSAC Men’s Basketball Conference Championship NCAA Division II Softball National Championship Tournament NCAA Division II Eastern Regional Wrestling Championship Tournament NCAA Division II Super Regional Softball Tournament PSAC Softball Conference Championship Tournament NCAA Division II Eastern Regional Field Hockey Tournament NCAA Division II National Wrestling Championship Tournament PSAC Wrestling Conference Championship Tournament PSAC Volleyball Conference Championship Tournament NCAA Division II North Atlantic Regional Baseball Championship Tournament PSAC Baseball Conference Championship Tournament PSAC Women’s Basketball Conference Tournament 2018 2018 2019 2018 2017 2016 2014 2019 2019 2016-2018 2017 2015-2017 2015 2014-2015 2011-2014 2012-2013 2008-2015 2007 2006 2006 2015, 2014 2011-2014 2011, 2017 2006-Present 2019 2017-2019 2019 2018 2018,2019 2016 2016 2015 2012 2006- 2012 2006-2012 2006-2012 2007-2008 2006 2006-2011 2005-2012 2005 2005 2005 189 ECAC Division II Indoor Track and Field Championships 1992 Westminster College ECAC Division III Women’s Basketball Championship Tournament PAC Track and Field Conference Championships NCAA Division III Women’s National Soccer Championship Tournament NCAA Division III Men’s National Soccer Championship Tournament 2004 2003 2002-2003 2002 Sharon Regional Health System WPIAL Wrestling Tournament WPIAL Track Meet WPIAL Basketball Tournament 2002-2003 2002 2001-2002 190 191 192 193