THE AVAILABILITY OF CERTIFIED ATHLETIC TRAINERS IN HIGH
SCHOOLS IN MASSACHUSETTS

A THESIS
Submitted to the Faculty of the School of Graduate Studies
and Research
of
California University of Pennsylvania in partial
fulfillment of the requirements for the degree of
Master of Science

by
Kathryn Annunziata

Research Advisor, Dr. Carol Biddington
California, Pennsylvania
2011

ii

iii
ACKNOWLEDGEMENTS
First and foremost, I would like to thank my wonderful
parents. Thank you for always being there for me and
supporting me in whatever I am doing. To Tricia, Andrew and
Kristen for being the most amazing older siblings anyone
could ever have and for always helping me through anything.
To Jojo, thank you for always encouraging me and being
there to talk when I needed it. I love you all so much!
To Robbie, you were always there to listen to my
problems and help me relax during all those stressful
nights working on my thesis. You’ve helped me through this
past year more than you’ll ever know and I’m so grateful
for you. I love you!
Thank you to my girls Joanna, Jackie, and Kristin. We
all became so close in such a short amount of time and made
some great memories this year. I’m definitely going to
miss living together and complaining about getting our
research done! You guys are the best.
I would like to give a huge thanks to my thesis
advisor, Dr. Carol Biddington. Thank you for all your
dedication to my research and for always pushing me in the
right direction. I’m so grateful for all of your help.
Also, thank you to my committee members, Dr. Karen Hjerpe
and Dr. Joni Roh for all their much needed assistance and
hard work.
I have to thank Ms. Martha Jamieson, MSSADA President
and Mr. Chris Aufiero, MSSADA Secretary for their help in
distributing my survey to all the high school Athletic
Directors in Massachusetts. Also, thank you to every
Massachusetts high school Athletic Director that was able
to take part in my survey. This study could not have been
completed without your help.

iv
TABLE OF CONTENTS
Page
SIGNATURE PAGE

. . . . . . . . . . . . . . . . ii

AKNOWLEDGEMENTS . . . . . . . . . . . . . . . . iii
TABLE OF CONTENTS
LIST OF TABLES

. . . . . . . . . . . . . . . . vii

LIST OF FIGURES .
INTRODUCTION
METHODS

. . . . . . . . . . . . . . . iv

. . . . . . . . . . . . . . . viii

. . . . . . . . . . . . . . . . . 1

. . . . . . . . . . . . . . . . . . . 6

Research Design. . . . . . . . . . . . . . . . 6
Subjects

. . . . . . . . . . . . . . . . .

Preliminary Research

. 7

. . . . . . . . . . . . . 7

Instruments . . . . . . . . . . . . . . . . . 7
Procedures

. . . . . . . . . . . . . . . . . 8

Hypotheses

. . . . . . . . . . . . . . . . . 9

Data Analysis
RESULTS

. . . . . . . . . . . . . . . . 10

. . . . . . . . . . . . . . . . . . . 11

Demographic Data . . . . . . . . . . . . . . . 11
Hypotheses Testing

. . . . . . . . . . . . . . 21

Additional Findings . . . . . . . . . . . . . . 25
DISCUSSION .

. . . . . . . . . . . . . . . . . 30

Discussion of Findings . . . . . . . . . . . . . 30
Conclusions . . . . . . . . . . . . . . . . . 35

v
Recommendations. . . . . . . . . . . . . . . . 36
REFERENCES . . . . . . . . . . . . . . . . . . 38
APPENDICES . . . . . . . . . . . . . . . . . . 40
APPENDIX A: Review of the Literature . . . . . . . . 41
What is Athletic Training?

. . . . . . . . . . . 43

Certified Athletic Trainers in High Schools
Injuries in the High School Setting
Massachusetts
Budgets

. . . . 45

. . . . . 48

. . . . . . . . . . . . . . . . 51

. . . . . . . . . . . . . . . . . 51

Health Care . . . . . . . . . . . . . . . . 53
Summary

. . . . . . . . . . . . . . . . . . . 54

APPENDIX B: The Problem . . . . . . . . . . . . . 57
Statement of the Problem . . . . . . . . . . 58
Definition of Terms . . . . . . . . . . . . . 59
Basic Assumptions . . . . . . . . . . . . . . 59
Limitations of the Study . . . . . . . . . . . 60
Significance of the Study. . . . . . . . . . . 60
APPENDIX C: Additional Methods . . . . . . . . . . 62
Panel of Experts Letter (C1)

. . . . . . . . . . 63

High School Certified Athletic Trainer Availability
Survey (C2)

. . . . . . . . . . . . . . . . . 65

Institutional Review Board (C3) . . . . . . . . . 70
Cover Letter to Participants
REFERENCES

(C4) . . . . . . . . 81

. . . . . . . . . . . . . . . . . 84

vi
ABSTRACT . . . . . . . . . . . . . . . . . . . 89

vii
LIST OF TABLES

Tables

Page

1. Certified Athletic Trainers at High Schools.

. . . . 11

2. Medical Personnel Providing Athletic Health Care . . . 11
3. Number of Certified Athletic Trainers at High Schools . 12
4. Years ATC has Worked at High Schools. . . . . . . . 12
5. Certified Athletic Trainers at High Schools.

. . . . 12

6. Hours Per Week Worked By ATC s. . . . . . . . . . . 13
7. Why High Schools Do Not Have an ATC . . . . . . . . 13
8. Satisfaction with Medical Coverage. . . . . . . . . 14
9. Type of Institution

. . . . . . . . . . . . . . 14

10. Divisional Classification
11. Boys’ Varsity Sports

. . . . . . . . . . . 15

. . . . . . . . . . . . . 16

12. Girls’ Varsity Sports . . . . . . . . . . . . . 17
13. Practice Coverage by Certified Athletic Trainer . . . 18
14. Game Coverage by Certified Athletic Trainer

. . . . 19

15. Athletic Budgets . . . . . . . . . . . . . . . 20
16. A MANOVA for Athletic Budget, Girls’ Varsity Sports,
and Boys’ Varsity Sports . . . . . . . . . . . . 22
17. Pearson Correlation Between Athletic Budget, Boys’
Varsity Sports, and Girls’ Varsity Sports . . . . . 26

viii
LIST OF FIGURES

Figures

Page

1. Boys’ Varsity Sports Versus Girls’ Varsity Sports . . . 17
2. Employing a Certified Athletic Trainer Based Upon the
Number of Girls’ Varsity Sports . . . . . . . . . . 23
3. Employing a Certified Athletic Trainer Based Upon
Athletic Budget

. . . . . . . . . . . . . . . . 24

4. Scatterplot Comparing Boys’ Varsity Sports Teams with
Girls’ Varsity Sports Teams . . . . . . . . . . . . 27
5. Scatterplot Comparing Boys’ Varsity Sports Teams with
Athletic Budget

. . . . . . . . . . . . . . . . 28

6. Scatterplot Comparing Girls’ Varsity Sports Teams with
Athletic Budget

. . . . . . . . . . . . . . . . 29

1
INTRODUCTION

When athletes sustain athletic injuries, the certified
Athletic Trainer is the first person of contact on the
sports medicine team to evaluate the athlete and injury.

A

certified Athletic Trainer is a sports medicine
professional who collaborates with physicians to optimize
patient and client activity and participation in athletics,
work, and life.1-3

Certified Athletic Trainers are properly

educated and trained in the area of sports medicine and
have the ability, thus qualifying them to recognize and
treat athletic injuries seen at various levels of
competition.

At a minimum, to become a certified Athletic

Trainer, one must hold a bachelor’s degree and pass a
national certification examination specific to the
competencies of a certified Athletic Trainer outlined by
the National Athletic Trainers’ Association (NATA) and The
Board of Certification (BOC).4

To maintain certification,

certified Athletic Trainers must attend workshops or
complete courses yearly and earn 80 continuing education
units in a three year period.

Certified Athletic trainers

are well educated professionals in the field of sports
medicine prepared to prevent, evaluate, rehabilitate, and
manage athletic injuries at any given participation level

2
(i.e., high school, college, professional, elite, etc.).
In fact, nearly 70% hold a master’s degree or higher
advanced degree.4
High school sports participation is nearly 20 times
greater than NCAA participation,5 and in 2005, more than 7
million high school students were participating in
interscholastic athletics in the United States.6

With the

large number of students involved in athletics, injuries
sustained during practices and competition are inevitable.
In the 2005-2006 school year alone; athletes participating
in football, soccer, basketball, wrestling, volleyball,
baseball, and softball sustained an estimated 1.4 million
injuries.7 Injuries sustained by high school athletes have
resulted in 500,000 doctor visits, 30,000 hospitalizations
and a total cost to the healthcare system of nearly 2
billion dollars per year.8
While participating in athletics can be beneficial,
children are getting injured at a very high rate in the
secondary school setting.

If a high school athlete

sustains an injury and his or her family cannot afford
insurance, what option do they have for treatment?
Employing a certified Athletic Trainer at all high schools
could help reduce doctor visits because a certified
Athletic Trainer would be able to differentiate between

3
acute injuries and injuries that require a referral for
more specialized medical attention. One study examined that
there is an average of 2.6 million emergency department
visits for sports-related injuries per year.9 A certified
Athletic Trainer in the high school could provide that
uninsured child initially with the appropriate medical
attention they deserve, thus reducing the number of visits
to the emergency room and medical costs.
Many Americans struggle with paying for health
insurance for themselves and their families.

For example,

in the 2008 tax year, about 50,000 Massachusetts residents
were still without health insurance because they could not
afford it.10 About 55% of Massachusetts residents stated
that there was a time in 2009 that they needed medical
care, tests, or treatments but were unable to get them due
to being uninsured.

Even though Massachusetts has tried to

introduce legislature to insure every resident, there is
still a significant amount of people living with no health
insurance.
With the overwhelming number of student-athletes at
the high school level, athletic health care should be
accessible to every child participating in athletic
competition.

Certified Athletic Trainers can provide

effective athletic health care and should be available for

4
athletes at every high school in the United States.
However, many high schools across the country do not employ
a certified Athletic Trainer.

In fact, as of 1999, Hawaii

was the only state in the United States that required a
certified Athletic Trainer to be employed at all public
high schools.11 Certified Athletic Trainers are highly
educated medical professionals that can provide exceptional
care to athletes of all ages and may help many of these
families without health care receive appropriate medical
attention without the high costs.
It is not unreasonable to think that a high percentage
of certified Athletic Trainers would be employed at the
secondary school level.

However, according to the NATA only

42% of high schools have access to a certified Athletic
Trainer12 and according to the NATA, about 21 percent of
NATA members provide service to secondary schools.13
This study will attempt to answer the following
questions: 1) Is having a certified Athletic Trainer in
Massachusetts dependent on school divisional classification
(I, II, III, IV)? 2) Are high schools with a higher
athletic budget more likely to employ a certified Athletic
Trainer than high schools with lower athletic budgets? and
3) Are high schools with more varsity sports teams more
likely to employ a certified Athletic Trainer than high

5
schools with less varsity sports teams for A) boys’ and B)
girls’?

6
METHODS

This section includes the following subsections:
Research Design, Subjects, Preliminary Research,
Instrument, Procedures, Hypotheses, and Data Analysis.

Research Design

A descriptive design was used in this study.

The

dependent variables in this study were the athletic budget
of the high schools and the number of varsity sports at the
high schools.

The independent variables of this study were

high schools with or without a certified Athletic Trainer
and the school’s divisional classification (I, II, III,
IV).
The strength of this study is that content validity
was established for the survey after a review by a panel of
experts.

The limitation of this study was that only

athletic directors in high schools in Massachusetts were
surveyed.

7
Subjects

The number of subjects for this study was 44 out of
371 athletic directors at public and private high schools
in Massachusetts for a return rate of 11.8%.

Sampling

included the entire population of athletic directors in
Massachusetts.

Informed consent was implied with

completion and return of the survey.

Preliminary Research

A review of the survey was conducted by a panel of
experts (Appendix C1).

This panel reviewed the survey and

provided suggestions for improvements and changes.

The

panel includes a college sports medicine Program Director,
a high school Athletic Director and a head high school
certified Athletic Trainer.

Instrument

The High School Certified Athletic Trainer
Availability Survey (Appendix C2) was used in this study
and was available for the Athletic Directors to complete on
www.surveymonkey.com.

This survey was developed by the

8
researcher for the purpose of determining the prevalence of
certified Athletic Trainers in high schools in
Massachusetts.

The survey asked for information regarding

athletic training coverage by a certified Athletic Trainer
at the school.

There were questions regarding the amount

of hours per week a school’s certified Athletic Trainer
works and how many full time and part time certified
Athletic Trainers are employed at the high school.

The

Athletic Director indicated the number and type of varsity
sports teams and provided information regarding the
athletic budget.

There were a total of 16 questions the

Athletic Directors completed in the survey.

Procedures

The survey was finalized after review by a panel of
experts.

An application was sent to California University

of Pennsylvania’s Institutional Review Board for Protection
of Human Subjects (Appendix C3) for approval before the
study was conducted.

A survey was created by the

researcher and was sent electronically to 371 high school
Athletic Directors in Massachusetts.

The researcher

contacted the President of the Massachusetts Secondary
Schools Athletic Directors Association (MSSADA) to

9
distribute the survey to all Massachusetts high school
Athletic Directors via email.

Martha Jamieson, MSSADA

President, granted Chris Aufiero, association Secretary,
permission to distribute the survey.

A Cover Letter to

Participants (Appendix C4) was sent explaining the purpose
of the study to the Athletic Directors and a link was also
provided to access the survey.

The researcher did not have

the email addresses of the Athletic Directors, therefore
responses were anonymous.

The researcher allowed the

Athletic Directors time to complete and return the survey.
The Athletic Directors were sent a second email 7-10 days
after the initial email as a reminder to complete the
survey before the indicated deadline.

Hypotheses

These hypotheses were formed based on the literature
review and the theories of the researcher.
H1: Having a certified Athletic Trainer will be dependent
on the school’s divisional classification (division I,
division II, division III, division IV).
H2: High schools with a higher athletic budget will be more
likely to employ a certified Athletic Trainer than high
schools with a lower athletic budget.

10
H3: High schools with more varsity sports teams will be
more likely to employ a certified Athletic Trainer than
high schools with less varsity sports teams for A) boys and
B) girls.

Data Analysis

The level of significance was set at 0.05.
H1: A 2 (Having a certified Athletic Trainer – yes/no) X 4
(School divisional classification- division I, II, III, IV)
Chi square test of independence was used to determine if
having a certified Athletic Trainer was dependent on a
school’s divisional classification.
H2 and H3: A MANOVA test was used to determine if high
schools with higher athletic budgets were more likely to
employ a certified Athletic Trainer than high schools with
lower athletic budgets and if high schools with more
varsity sports teams were more likely to employ a certified
Athletic Trainer than high schools with less varsity sports
teams for A) boys and B) girls.

11
RESULTS
Demographic Data
Massachusetts high school Athletic Directors (N = 44),
which was a response rate of 11.9%, voluntarily
participated in this survey.

Table 1 represents the

certified Athletic Trainers employed at high schools.

Over

half of the Athletic Directors that responded stated they
have a certified Athletic Trainer at their high school.
Table 1. Certified Athletic Trainers at High Schools
Characteristic
Frequency
Percent
Yes
25
56.8
No
18
40.9
Other
1
2.3

Table 2 represents the medical personnel that the
Athletic Directors reported provided athletic health care
to their athletes if they did not employ a certified
Athletic Trainer.

The most common medical personnel that

the Athletic Directors indicated cared for their student
athletes were EMTs.
Table 2. Medical Personnel Providing Athletic Health Care
Characteristic
Frequency
Percent
EMT
17
38.6
Nurse
13
29.5
Coach
13
29.5
Physician
4
9.1

12
Table 3 shows the number of certified Athletic
Trainers employed at the Massachusetts high schools, as
indicated by the Athletic Directors.

Some schools reported

that they had no certified Athletic Trainer, while one
school’s Athletic Director indicated that they had 20.
Table 3. Number of Certified Athletic Trainers at High
Schools
Classification
Min.
Max.
Mean
SD
Number of ATC
0
20
1.14
3.041

Table 4 represents the number of years that each high
school has employed a certified Athletic Trainer.

The

highest number of years that a high school employed a
certified Athletic Trainer was 33 years.
Table 4. Years ATC has Worked at High School
Classification
Min.
Max.
Mean
Years
0
33
9.08

SD
9.705

Table 5 represents the certified Athletic Trainer
employed at high schools full-time and part-time.

More

schools employed a part-time certified Athletic Trainer
over a full-time.

There were twice as many part-time

certified Athletic Trainers as compared to full-time.
Table 5. Certified Athletic Trainers at High Schools
Characteristic
Frequency
Percent
Part-time
26
59.1
Full-time
13
29.5
No Response
5
11.4

13
Table 6 represents the approximate hours worked by the
certified Athletic Trainers at the high schools.

The most

hours worked by a certified Athletic Trainer per week was
approximately 50 hours.
Table 6. Hours Per Week Worked By ATC
Classification
Min.
Max.
Hours
0
50

Mean
23.53

SD
16.761

Table 7 identifies the reasons why 27.27% of high
schools may not employ a certified Athletic Trainer.

The

primary reason for a high school to not employ a certified
Athletic Trainer was that they did not have enough money in
their budget.

One Athletic Director in particular stated

that the administration at his/her school did not realize
the importance of having a certified Athletic Trainer on
staff.
Table 7. Why High Schools Do Not Have an ATC
Characteristic
Frequency
Not enough money
7
Care provided by other personnel
3
No affiliation with local clinic
1
Other
1
Have ATC
32

Percent
58.3
25.0
8.3
2.3
6.1

Massachusetts high school Athletic Directors were
asked to report if they were satisfied with the medical
professionals that provided athletic health care to their
student-athletes.

Over 50 percent of Athletic Directors

14
indicated that they were satisfied with the medical
professionals that provided their student athletes with
athletic health care. (See Table 8).
Table 8. Satisfaction with Medical Coverage
Characteristic
Frequency
Yes
24
No
10
Other
10

Percent
54.5
22.7
22.8

The Athletic Directors were asked to state whether
their high school was a public or private institution.
Only 11% Athletic Directors indicated that their school was
private, while 65.9% schools were public institutions. (See
Table 9).
Table 9. Type of Institution
Characteristic
Public
Private
Other

Frequency
29
5
10

Percent
65.9
11.4
22.7

The Athletic Directors were asked to report the
divisional classification for their high school.

They were

asked to indicate either division I, division II, division
III, or division IV on the survey.
division was division I.

The most common

In Massachusetts, division I

schools are the largest while division IV are the smallest.
(See Table 10).

15
Table 10. Divisional Classification
Characteristic
Frequency
Division I
12
Division III
9
Division II
7
Division IV
6
Other
10

Percent
27.3
20.5
15.9
13.6
22.7

Table 11 represents the number of boys’ varsity sports
at the high schools.

In the same question, the Athletic

Directors also indicated the sports for their high school.
The most boys’ varsity sports as reported by the Athletic
Directors were 36 sports teams.

Some Athletic Directors

indicated that they had additional sports than those
provided, which included sailing, Alpine skiing,
cheerleading, cross country, crew, cross country skiing,
Nordic skiing, and fencing.

One Athletic Director stated

that they had no boys’ varsity sports teams because his/her
institution was an all girls’ school.

16
Table 11. Boys’ Varsity Sports
Classification
Min. Max.
Number of boys’ sports
0
36

Characteristic
Baseball
Basketball
Soccer
Football
Outdoor Track
Golf
Tennis
Ice Hockey
Indoor Track
Wrestling
Swimming/Diving
Lacrosse
Volleyball
Gymnastics
Field Hockey

Mean
11.97

Frequency
30
30
29
28
28
27
24
22
20
19
17
15
13
4
2

SD
7.460

Percent
68.2
68.2
65.9
63.6
63.6
61.4
54.5
50.0
45.5
43.2
38.6
34.1
29.5
9.1
4.5

The Athletic Directors were asked to specify how many
girls’ varsity sports teams they had at their high school.
They also indicated which girls’ varsity sports they had.
The highest number of girls’ varsity sports at the high
schools was 18 teams.

Some Athletic Directors reported

additional sports teams than those provided, which included
cheerleading, cross country, Nordic skiing, Alpine skiing,
crew, fencing, dance, and sailing. (See Table 12).

17
Table 12. Girls’ Varsity Sports
Classification
Min.
Max.
Number of girls’ sports
5
18

Characteristic
Soccer
Softball
Basketball
Outdoor Track
Tennis
Volleyball
Field Hockey
Indoor Track
Swimming/Diving
Lacrosse
Golf
Gymnastics
Ice Hockey
Skiing
Wrestling

Frequency
33
33
32
31
28
26
23
23
22
20
14
13
13
12
4

Mean
11.27

SD
3.752

Percent
75.0
75.0
72.7
70.5
63.6
59.1
52.3
52.3
50.0
45.5
31.8
29.5
29.5
27.3
9.1

Figure 1. Boys’ Varsity Sports Versus Girls’ Varsity Sports

18
Table 13 shows the varsity sports that have coverage
by a certified Athletic Trainer at their practices. Some
Athletic Directors stated that they had practice coverage
at sports like cheerleading, cross country, sailing, Nordic
skiing, and Alpine skiing.
Table 13. Practice Coverage by Certified Athletic Trainer
Characteristic
Frequency
Percent
Football
20
45.5
Girls Basketball
18
40.9
Girls Soccer
18
40.9
Girls Outdoor Track
17
38.6
Boys Basketball
16
36.4
Softball
16
36.4
Boys Outdoor Track
16
36.4
Baseball
15
34.1
Boys Soccer
15
34.1
Girls Field Hockey
14
31.8
Girls Lacrosse
14
31.8
Boys Lacrosse
13
29.5
Girls Volleyball
13
29.5
Girls Indoor Track
12
27.3
Boys Wrestling
12
27.3
Girls Tennis
11
25.0
Boys Outdoor Track
11
25.0
Boys Tennis
10
22.7
Boys Volleyball
7
15.9
Boys Swimming/Diving
5
11.4
Girls Swimming/Diving
5
11.4
Girls Gymnastics
4
9.1
Boys Ice Hockey
3
6.8
Girls Ice Hockey
3
6.8
Boys Golf
2
4.5
Girls Golf
2
4.5
Boys Gymnastics
2
4.5
Girls Wrestling
2
4.5
Boys Field Hockey
1
2.3
Boys Skiing
1
2.3
Girls Skiing
1
2.3

19
Table 14 shows the varsity sports that have coverage
by a certified Athletic Trainer at their games.

The

Athletic Directors also indicated sports like cheerleading,
cross country, sailing, Nordic skiing, and Alpine skiing
had a certified Athletic Trainer covering their games or
competitions.
Table 14. Game Coverage by Certified Athletic Trainer
Characteristic
Frequency
Percent
Football
24
54.5
Girls Basketball
24
54.5
Boys Basketball
21
47.7
Girls Soccer
20
45.5
Boys Ice Hockey
19
43.2
Softball
19
43.2
Baseball
18
40.9
Girls Lacrosse
18
40.9
Boys Soccer
18
40.9
Girls Outdoor Track
17
38.6
Girls Field Hockey
16
36.4
Boys Lacrosse
16
36.4
Boys Outdoor Track
16
36.4
Boys Wrestling
16
36.4
Girls Volleyball
16
36.4
Girls Tennis
14
31.8
Girls Ice Hockey
12
27.3
Boys Tennis
11
25.0
Girls Indoor Track
11
25.0
Boys Indoor Track
10
22.7
Boys Volleyball
8
18.2
Girls Gymnastics
7
15.9
Boys Swimming/Diving
4
9.1
Girls Swimming/Diving
4
9.1
Girls Skiing
2
4.5
Girls Wrestling
2
4.5
Boys Golf
1
2.3
Girls Golf
1
2.3
Boys Gymnastics
1
2.3
Boys Skiing
1
2.3

20
The Athletic Directors were asked to report their
school’s athletic budget.

The highest athletic budget

indicated was $1,000,000 by one Athletic Director. (See
Table 15).
Table 15. Athletic Budgets
Classification
Min.
Max.
Athletic Budget 45,000 1,000,000

Mean
373,007.93

SD
272,546.125

21
Hypotheses Testing

The hypotheses were tested at a level of 0.05.
Hypothesis 1: A chi square test of independence was used to
determine if having a certified Athletic Trainer was
dependent on the school’s divisional classification (DI,
DII, DIII, DIV).
Conclusion: There were not enough subjects to run the data
analysis.

Hypotheses 2 & 3:

A MANOVA test was used to determine if

high schools with higher athletic budgets were more likely
to employ a certified Athletic Trainer than high schools
with lower athletic budgets and if high schools with more
varsity sports teams were more likely to employ a certified
Athletic Trainer than high schools with less varsity sports
teams for A) boys’ and B) girls’.
Conclusion: A MANOVA was calculated examining if high
schools with a higher athletic budget were more likely to
employ a certified Athletic Trainer than high schools with
lower athletic budgets and if high schools with more
varsity sports teams were more likely to employ a certified
Athletic Trainer than high schools with less varsity sports
teams for A) boys’ and B) girls’.

A significant effect was

22
found (Lambda(3,25)=.680, p=.020).

Follow-up univariate

ANOVAS indicated that employing a certified Athletic
Trainer significantly improved with high athletic budgets
(F(1,27)=7.406, p=.011) and employing a certified Athletic
Trainer significantly improved with more girls’ varsity
sports (F(1,27)=11.677, p=.002).

No significant effect was

found (F(1,27)= 3.200, p >.05) when examining if high
schools with more boys’ varsity sports were more likely to
employ a certified Athletic Trainer.
Table 16. A MANOVA for Athletic Budget, Girls’ Varsity
Sports, and Boys’ Varsity Sports
Source Dependent Type III
df
MS
F
Variable
Sum of
Squares
AB*
4.477E11
1
GVS*
130.072
1
BVS*
170.354
1
* AB (Athletic Budget), GVS (Girls’
(Boys’ Varsity Sports)

4.477E11 7.406
22596.891 11.677
170.354
3.200
Varsity Sports),

P

.011
.002
.085
BVS

23

YES

NO

Figure 2. Employing a Certified Athletic Trainer Based Upon
the Number of Girls’ Varsity Sports

24

YES

NO

Figure 3. Employing a Certified Athletic Trainer Based Upon
Athletic Budget

25
Additional Findings

Table 17 displays a Pearson correlation between
athletic budget of the high schools, the amount of boys’
varsity sports, and girls’ varsity sports.

A moderate

correlation was found (r(31)=.480, p < .005) between the
number of boys’ varsity sports and the number of girls’
varsity sports.

A strong positive correlation was found

(r(27)=.751, p < .001) between the athletic budget and the
number of boys’ varsity sports, indicating a significant
linear relationship between the two variables.

This

indicates that schools with higher athletic budgets tended
to have more boys’ varsity sports teams.

A moderate

positive correlation was found (r(27)= .664, p < .001)
between the athletic budget and girls’ varsity sports.

26
Table 17. Pearson Correlation Between Athletic Budget,
Boys’ Varsity Sports, and Girls’ Varsity Sports
BVS*
GVS*
AB*
BVS
Pearson
Sig(2tail)
N
GVS
Pearson
.480
Sig(2tail)
.005
N
33
AB
Pearson
.751
.664
Sig(2tail)
.000
.000
N
29
29
*BVS (Boys’ Varsity Sports), GVS (Girls’ Varsity Sports),
AB (Athletic Budget)

27

Figure 4. Scatterplot Comparing Boys’ Varsity Sports Teams
with Girls’ Varsity Sports Teams.

28

Figure 5. Scatterplot Comparing Boys’ Varsity Sports Teams
with Athletic Budget.

29

Figure 6. Scatterplot Comparing Girls’ Varsity Sports Teams
with Athletic Budget.

30
DISCUSSION

The following section will include: 1) Discussion of
Results, 2) Conclusions, and 3) Recommendations.

Discussion of Results

This study focused on certified Athletic Trainers
employed at high schools in the Commonwealth of
Massachusetts.

Certified Athletic Trainers are trained

medical professionals that can provide athletes of all ages
with appropriate athletic health care.

Many high schools

across the country do not employ a certified Athletic
Trainer and need someone they can rely on to care for their
student-athletes.
In 2005, more than 7 million high school students were
participating in interscholastic athletics in the United
States.6 Even with this significantly high amount of
students participating in athletics at the secondary school
level, according to the National Athletic Trainers’
Association only 42% of high schools have access to a
certified Athletic Trainer.12

As of 1999, Hawaii was the

only state in the Unites States that required a certified
Athletic Trainer to be employed at all public high

31
schools.11 With so many high school participants, there
needs to be a medical professional available to these
athletes to provide effective athletic health care when
injuries occur.

It was found that 56.8% of the 44 high

school Athletic Directors in the commonwealth of
Massachusetts that participated in this study have a
certified Athletic Trainer on staff.

Over half (51.9%) are

full-time employees while 29.5% are part-time employees.
Health care coverage has become a growing issue for
many Americans.

In Massachusetts, about 50,000 residents

in the 2008 year were still without any type of health care
coverage.10 Even though legislation was introduced in the
state in order to ultimately cover every resident, there
are still significant amounts of people without health care
coverage.

These people without health insurance need to

have somewhere to turn when faced with athletic injuries.
Having a certified Athletic Trainer at every high school
could help those people without any health coverage get the
medical attention they need.

A certified Athletic Trainer

at their institution could help those people without any
health insurance and could have somewhere to turn when
faced with an injury.
This study tried to determine if having a certified
Athletic Trainer was dependent on the school’s divisional

32
classification (DI, DII, DIII, DIV).

However, with only

44 Athletic Directors responding to the survey, there was
not enough data to run an analysis.

Division I schools in

Massachusetts are the largest class of schools, so it’s not
surprising to see that they are more likely to have a
certified Athletic Trainer as opposed to smaller schools.
In other studies such as Biddington et al,14 it was found
that class AAAA, being the largest in the state of
Pennsylvania, were more likely to employ a certified
Athletic Trainer as opposed to smaller schools.
The results from this study found that schools with
higher athletic budgets were more likely to hire a
certified Athletic Trainer.

This finding suggests that

schools that have more money allotted to their athletic
program will probably have extra money to put towards
additional costs such as hiring a certified Athletic
Trainer.

It was also found that employing a certified

Athletic Trainer significantly improved with more girls’
varsity sports.

Emerging evidence indicates that female

high school and college athletes in basketball, soccer,
lacrosse, field hockey, and skiing experience a greater
number of knee and ankle injuries than their male
counterparts.15

This may suggest why schools with a higher

number of girls’ varsity sports teams may be more likely to

33
have a certified Athletic Trainer.

However, high schools

with a higher number of boys’ varsity sport were not likely
to have a certified Athletic Trainer. It was believed that
having a certified Athletic Trainer would be dependent on
the number of varsity sports at a high school because with
more athletes, there will be more injuries and therefore
more need for someone readily available to student-athletes
to care for their injuries.
This study asked Athletic Directors to indicate which
sports had coverage by certified Athletic Trainers at
practices and games.

During practices, the sport with the

most coverage is football at 45.5%.

This seems like an

appropriate result since football is considered a high
contact sport.

However, boy’s ice hockey only had 6.8% of

coverage at practices.

Boy’s ice hockey is another high

contact sport and should have a certified Athletic Trainer
at practices at a higher percentage.

For game coverage,

football was again the highest at 54.5% of coverage by a
certified Athletic Trainer.

However, girls’ basketball has

the same percentage while higher contact sports like boys’
ice hockey and boys’ lacrosse have lower percentages.
A strong correlation was found between athletic
budgets and the number of boys’ varsity sports, indicating
that high schools with higher athletic budgets tended to

34
have more boys’ varsity sports teams.

A moderate

correlation was found between athletic budgets and girls’
varsity sports.

These results show that the more sports a

school has, the more money they will need.

A moderate

correlation was found between boys’ varsity sports and
girls’ varsity sports.

This may show that schools are

trying to offer the same opportunities to both boys and
girls regardless of school size.
In regards to the correlation between boys’ varsity
sports and girls’ varsity sports, it was stated that the
maximum amount of boys’ varsity sports teams was 36, while
the maximum amount of girls’ varsity sports was 18.
Schools were generally equal in their boys’ and girls’
sports, where the 36 boys’ sports could have been an
outlier.

Title IX legislation states that girls and women

in high school and college should have the same
opportunities.16 These results reflect how Title IX has
helped girls’ high school sports because the girls seem to
have the same opportunity as boys.

35
Conclusions

After reviewing the results of this study, it can be
concluded that high schools in Massachusetts are taking it
upon themselves to recognize the need for certified
Athletic Trainers at the secondary school level.

There is

no legislation in the state requiring high schools to
employ a certified Athletic Trainer, however over half of
the high schools surveyed have one on staff.

Of the

schools that responded to the study, more division I high
schools have certified Athletic Trainers as opposed to
division IV, which is the smallest in Massachusetts.

While

it may be difficult due to budget restraints, smaller
schools need to start employing certified Athletic
Trainers.
One area which needs improvement is coverage of higher
contact sports by each school.

There can be devastating

injuries during high contact sports competition and there
needs to be someone there during play who can aid in
helping injured student-athletes.

When asked if satisfied

with the medical coverage at their high school, more than
half of the Athletic Directors participating in this survey
responded that they were.

Even though high schools in the

state are still without a certified Athletic Trainer, the

36
56.8% of the 44 high schools participating in this study
that employ a certified Athletic Trainer are pleased with
the services they provide to the student-athletes.

Recommendations

The purpose of this study was to see how many high
schools in Massachusetts employed a certified Athletic
Trainer.

After reviewing the results, a recommendation to

Massachusetts would be to introduce legislation that would
require all high schools to have a certified Athletic
Trainer on staff.

To perhaps gain better and more accurate

results, a study on this same state with a higher response
rate may be necessary.

Only 44 (11.9%) of the 371 Athletic

Directors contacted to participate in this study completed
the survey and therefore a study with more responses may
prove more accurate.
It would also be beneficial for future studies to
examine other states and their high school athletic health
care coverage.

Studying more states will give us a better

picture of certified Athletic Trainers working at the high
school level and which states have better coverage as
opposed to others.

37
Choosing another population to sample may provide
researchers with better response rates.

This study asked

Athletic Directors to respond to a survey about athletic
health care at their high schools and there was a low
response rate of only 11.9%.

Sampling another population

might garner high results since Athletic Directors may not
have all the information when it comes to certified
Athletic Trainers.

There may be other personnel in the

high school who could provide more accurate results and
hopefully higher response rates.
Future research can focus on state sizes and comparing
if bigger states have more high school certified Athletic
trainers as opposed to smaller states.

38
REFERENCES

1.

National Athletic Trainers Association. Athletic
training services. Available at:
http://nata.org/sites/default/files/GuideToAthleticTra
iningServices.pdf. Accessed June 29, 2010.

2.

Board of Certification. What is an athletic trainer?
Available at: http://www.bocatc.org. Accessed on June
29, 2010.

3.

Board of Certification. Defining athletic training.
Available at: http://www.bocatc.org/athtrainer/DEFINE.
Accessed September 13, 2010.

4.

National Athletic Trainers Association. The facts
about athletic trainers. Available at:
http://nata.org/sites/default/files/AT_facts.pdf.
Accessed December 7, 2010.

5.

Claiborne T, Hou S, Cappaert T. Certified athletic
trainers provide effective care in the high school
setting. Athletic Therapy Today. 2007;12(2):34-38.

6.

Almquist J, McLeod TC, Cavanna A, et al. Summary
statement: Appropriate medical care for the secondary
school aged athlete. J Athl Train. 2008;43(4):416-427.

7.

Yard EE, Collins CL, Comstock RD. A comparison of high
school sports injury surveillance data reporting by
certified athletic trainers and coaches. J Athl Train.
2009;44(6):645-652.

8.

Adirim TA, Cheng TL. Overview of injuries in the young
athlete. Sports Med 2003;33(1):75-81.

9.

Burt CW, Overpeck MD. Emergency visits for sportsrelated injuries. Ann Emerg Med 2001;37(3):301-6.

39
10.

Health connector, health insurance for Massachusetts
residents: health reform facts and figures fall 2010.
Available at:
https://www.mahealthconnector.org/portal/site/connecto
r/menuitem.d7b34e88a23468a2dbef6f47d7468a0c?fiShown=de
fault. Accessed October 26, 2010.

11.

Nichols AW. The role of athletic trainers and physical
therapists in sports medicine. Hawaii Med J.
1999(58):81-82.

12.

National Athletic Trainers Association. Athletic
trainers fill a necessary niche in secondary schools.
Available at: http://nata.org/NR031209. Accessed
December 10, 2010.

13.

National Athletic Trainers Association. Secondary
School Setting. Available at:
http://www.nata.org/athletic-training/jobsettings/secondary-schools-setting. Accessed April 12,
2011.

14.

Biddington C, Wagner RW, Lyles A, Brunner M. Athletic
health care in Pennsylvania high schools. Pennsylvania
J Health Physical Education Recreation Dance. 2009;2022.

15.

Whiteside P. Men’s and women’s injuries in comparable
sports. Phys Sportsmed. 1980;8(3):130-40.

16.

Women’s Sports Foundation. Understanding Title IX and
Athletics 101. Available at:
http://www.womenssportsfoundation.org/Issues-AndResearch/Title-IX.aspx. Accessed March 2011.

40

APPENDICES

41

APPENDIX A
Review of the Literature

42
Review of the Literature
Certified Athletic Trainers work in a variety of
health care settings.

The secondary school setting is

commonly overlooked as an environment for employment of an
Athletic Trainer often attributed to budget restraints or
location of the school.

While some high schools do have a

full time certified Athletic Trainer on staff, many schools
located throughout the United States may rely on services
provided by volunteer physicians, chiropractors, physical
therapists, and other such health care professionals who do
not specialize in appropriate sports medicine techniques.
High school student participation in athletics has grown
significantly and a growing need for certified Athletic
Trainers in high schools to provide medical care to injured
athletes should follow.

Massachusetts, like many states

have no current laws requiring certified Athletic Trainers
to work in every high school.

With the large increase in

athletic participation, more and more high schools will
start to need certified Athletic Trainers to care for
injured student-athletes.
The topics that will be discussed include: (1) What is
Athletic Training? (2) Athletic Trainers in High Schools,
(3) Injuries in the High School Setting, and (4)

43
Massachusetts.

Massachusetts will also include two

subsections: Budgets and Health care.

A summary of the

review of the literature will also be included.

What is Athletic Training?

A certified Athletic Trainer is a sports medicine
professional who collaborates with physicians to optimize
patient and client activity and participation in athletics,
work, and life.1

Certified Athletic Trainers specialize in

six domains which include prevention, clinical evaluation
and diagnosis, immediate care, treatment, rehabilitation
and reconditioning, organization and administration, and
professional responsibility.2

The profession of athletic

training is recognized by the American Medical Association
as a healthcare profession.3
Athletic training educational programs are accredited
by the Commission on Accreditation of Athletic Training
Education (CAATE).2,3

Students spend four years in an

undergraduate athletic training programs and become
knowledgeable in a variety of areas such as assessment and
evaluation, acute care, general medical conditions and
disabilities, pathology of injury and illness,
pharmacological aspects of injury and illness, nutritional

44
aspects of injury and illness, therapeutic exercise,
therapeutic modalities, risk management and injury
prevention, health care administration, professional
development and responsibility, and psychosocial
intervention and referral.3

Upon completion of an

undergraduate program, students may sit for a national
certification exam to become a certified Athletic Trainer.
Many certified Athletic Trainers continue their education
and about 70% hold a master’s degree or doctoral degree in
athletic training or related areas such as exercise
physiology, wellness and health promotion, or health care
administration.4
Certified Athletic Trainers can work in a variety of
settings including high schools, college, and sports
medicine clinics.5

Certified Athletic Trainers have a

unique education and set of skills that allow them to
properly assess and treat acute and traumatic injuries in
athletics.6

It is the belief of the National Athletic

Trainers Association and many other governing medical
bodies that injury situations at the high school level
should not be handled by laypersons that do not possess the
necessary skills in order to care for athletic injuries and
therefore high schools nationwide should employ a certified
Athletic Trainer.7

45
Certified Athletic Trainers in High Schools

There has been a 98% increase in high school athletic
participation between the years 1971 and 2005.8

With such a

drastic jump in student involvement in extracurricular
activities, certified Athletic Trainers in the secondary
school setting needs to increase as well.

The American

Medical Association issued a statement that the athletic
medicine unit of every high school should include an
athletic health coordinator who is preferably a certified
Athletic Trainer.9

A certified Athletic Trainer can reduce

injury occurrences and help to prevent re-injuries, thus
decreasing time lost from practice and game time.

Full-

time secondary school certified Athletic Trainers offer the
additional benefit of being available during the school-day
to assist the injured athlete with recovery by implementing
the instructions from the team or personal physician for
treatment of that injury.10

Providing these services on

campus can help to reduce lost instructional time for the
student athlete.

However, As of 1999, Hawaii was the only

state in the country that mandates athletic trainers in
every public high school.11

Every state in the United

States should have stricter regulations and laws that would
require certified Athletic Trainers in every high school.

46
Appropriate medical care of the secondary school-aged
individual involves more than basic emergency care during
sports participation.12

Many schools throughout the country

however rely on persons other than qualified sports
medicine professionals to handle athletic injuries.
Kentucky legislature has mandated that a coach from each
team in high schools must undergo advanced emergency sports
medicine training.13

Should parents feel that their

children are in good hands because a coach has a
certification that took them a few hours or weeks to
complete, when they could have a certified Athletic
Trainer, who has completed four or more years of school,
caring for their children?

Nurses are also being called in

to care for students beyond normal school hours and are
being put in charge of responding to athletic injuries.
Nursing, as a profession, does not have an extensive
knowledge of injury prevention or assessment of orthopaedic
injuries provided during basic nursing education.14
Certified Athletic Trainers are well educated in the
prevention of athletic injuries and how to properly
evaluate and assess athletic injury situations.

The

health, safety, and well-being of those participating in
high school athletics should be the priority of high
schools nationwide and therefore adequate personnel should

47
be on site to ensure that injuries are recognized early,
treated immediately, and allowed to heal properly.15
As high school athletics grow, the need for certified
Athletic Trainers to tend to athletic injuries grows as
well.

In a recent study, athletic health care coverage in

Pennsylvania found that 88.4% of high schools stated that
they had access to a certified Athletic Trainer.16

Even

with this number being relatively high, there were 17% of
schools without certified Athletic Trainers.

It was also

concluded that public schools were more likely to have
certified Athletic Trainers compared to private.

A study

identified the preparedness among Illinois high school
athletic departments, 73% of schools had a certified
Athletic Trainer.17

It was also found that 32% of schools

reported having coverage at practices, while 50% of schools
had coverage at games.

A study that examined medical

coverage in California revealed that 62% of high schools
reported some form of a certified Athletic Trainer on
campus either full time or part time.18

A study examining

medical coverage of high schools in North Carolina revealed
that only 56% of schools had coverage by a state certified
Athletic Trainer.19
No matter the type or size of high schools, a
certified Athletic Trainer should be employed at every high

48
school in the United States.

High schools should also not

differentiate between practices or games, requiring a
certified Athletic Trainer on school property at all times.
The remaining 49 states should join Hawaii in mandating
that certified Athletic Trainers be employed at all high
schools in order to keep athletic participation safe for
all student-athletes.

Injuries in the High School Setting

While the number of student-athletes in the secondary
setting has been growing over the past few decades, the
number of injuries sustained by participants has increased
as well.

The National Athletic Trainers’ Association

estimates that about one-third of the 7.5 million students
who play interscholastic sports will get hurt.20

Injuries

sustained by high school athletes have resulted in 500,000
doctor visits, 30,000 hospitalizations and a total cost to
the healthcare system of nearly 2 billion dollars per
year.21

To deal with the high amount of injuries seen at

the high school level, the Appropriate Medical Care for
Secondary School-Aged Athletes Task Force (AMCSSAA) was
developed in 2002 by the National Athletic Trainers’
Association to ensure young athletes were receiving

49
adequate medical care while participating in practices and
games.22 The task force is responsible for addressing
concerns like emergency care, prevention, and activities of
ongoing daily athletic health care in the secondary school
setting.
One study examining ankle injuries among high school
athletes found that approximately 326,396 ankles injuries
occurred nationally in 2005-2006, yielding an injury rate
of 5.23 ankle injuries per 10,000 athlete-exposures.23
Researchers found that sports that require jumping and
quick movements resulted in higher incidences of ankle
injuries.

While this study mainly focused on football,

soccer, volleyball, basketball, wrestling, baseball, and
softball, it can be concluded that any sport will require
jumping and fast movements and therefore, injuries can
occur while participating in any sport.
A certified Athletic Trainer who has been trained to
handle athletic injuries should be a staple at all high
schools.

However, many schools that do not employ

certified Athletic Trainers at their schools have to rely
on others to care for athletes.

This could be detrimental

to athletes because not only are personnel like school
nurses or coaches not educated to properly recognize and
treat athletic injuries, they also do not possess the

50
knowledge to properly prevent injuries and later record
information about them.
A study examining the assessment of high school
coaches’ knowledge of sports related concussions found that
there is a need for educating coaches in all areas of
sports related concussions, with particular emphasis placed
on prevention and basic early management of sports related
concussions.24

Certified Athletic Trainers are thoroughly

educated on early prevention of injuries, while coaches may
only attend various workshops to learn basic first aid
knowledge of sports injuries.

It is also an important

aspect of all medical professions to document injuries that
have been reported and record what treatment is given.

One

study examined the possibility of relying on coaches as
data reporters, which found that only 43% of enrolled
coaches completed necessary documents on injuries, but all
enrolled certified Athletic Trainers participated.25

High

schools should not have to rely on employees or outside
volunteers who are not trained to properly handle athletic
injury situations.

51
Massachusetts

With physical activity participation in Massachusetts
at 63%, the need for certified Athletic Trainers is a
concern.26

There are 7,536,753 students in the United

States participating in high school athletics, which
represents 55.2% of all enrolled students.27

With this

large amount of students participating in athletic
activities, injuries are inevitable and should be cared for
by certified Athletic Trainers. Many high schools across
the country, including those in the Commonwealth of
Massachusetts, are not always able to benefit from the
services of a certified Athletic Trainer.

Two thirds of

the nation’s public school sports programs lack a fulltime, certified Athletic Trainer.28

Budgets
Budgetary problems are often the main cause of high
schools throughout the country lacking a full-time Athletic
Trainer.

MetroWest Medical Center in Massachusetts

provides certified Athletic Trainers at a discount to seven
high schools who do not already employ a certified Athletic
Trainer.

Still, this program is limited in the amount of

certified Athletic Trainers they can lend out to area high

52
schools, with many of their employees working extra-long
hours to cover high school athletic events.

A high school

in Bellingham, Massachusetts left the program when they
hired a full-time certified athletic trainer several years
ago.

However, returned when budget cuts forced them to let

go of their certified Athletic Trainer this year.

Many

schools around the state and country are faced with the
same problem of a lack of athletic budgets to fund the
hiring of a certified Athletic Trainer.

Budgetary problems

plague high school programs, but just as coaches are
employed to develop skills and implement strategies,
certified Athletic Trainers are required to ensure safety
of the athletes and optimize their participation.29
While hiring a certified Athletic Trainer may pose an
increased cost to a high school, having one on staff would
be extremely beneficial. Many schools have compared the
cost of treating their injured athletes at local clinics
with treating them on-site under the supervision of an ATC.
They have found that their certified Athletic Trainers are
providing the equivalent to thousands of dollars of
athletic training services per year to their athletes.30,31,32
These comparisons suggest that it is financially feasible
and fiscally responsible to invest in employing a certified
Athletic Trainer.

53
Health Care
Health care coverage has been a growing issue among
Americans in the past few years.

In 2000, 83% of people

ages 18 or older had health care coverage in the United
States.33

Massachusetts is one of the few states that had a

higher number of people 18 years or older with health care
coverage at 92% in 2000.

In 2006, Massachusetts introduced

a healthcare reform effort to complement existing coverage
programs.34

The goal was to provide near-universal coverage

of the Massachusetts population. For tax year 2008, over
95% of tax filers were insured for the full year while
96.4% were insured at some point during the year, according
to the Massachusetts Department of Revenue.

An estimate by

the Division of Health Care Finance and Policy published in
October 2009 showed that 2.7% of Massachusetts residents
remain uninsured as of spring of 2009.

Even though this

number may be lower than the national average of uninsured
Americans, everyone in the United States should be able to
benefit from health care.
With the number of people in the Unites States still
without health care, it becomes difficult to find ways to
treat athletic injuries without paying too much to see a
health care professional.

Having certified Athletic

Trainers in the high school setting allows adolescents to

54
be seen by a qualified health care professional without
having to visit a hospital, clinic, or their personal
physician, thus saving a co-pay or examination payment.

In

states with fewer certified Athletic Trainers, a greater
share of injuries generally viewed as minor contusions,
abrasions, and dislocations were likely sent to the
emergency room than in states with more certified Athletic
Trainers.35

Having someone trained to know what requires

minor medical attention on site or what kind of injury
requires a 911 call can make all the difference.

Summary

The review of literature focuses on what athletic
training is, certified Athletic Trainers in high schools,
injuries at the high school level, and budgets and health
care in the Commonwealth of Massachusetts.

Certified

Athletic Trainers are allied health professionals that are
well educated in sports medicine health care.

Certified

Athletic Trainers become knowledgeable in a variety of
areas such as assessment and evaluation, acute care,
general medical conditions and disabilities, pathology of
injury and illness, pharmacological aspects of injury and
illness, nutritional aspects of injury and illness,

55
therapeutic exercise, therapeutic modalities, risk
management and injury prevention, health care
administration, professional development and
responsibility, and psychosocial intervention and referral.3
There should be a certified Athletic Trainer available
to student-athletes at all high schools across the country.
Only one state in the country currently requires certified
Athletic Trainers in every high school, but all studentathletes should be able to benefit from certified Athletic
Trainers.
With the large amount of participation in athletics in
the secondary school setting, injuries are an inevitable
part of competition.

Certified Athletic Trainers are

skilled in providing health care to athletes and could help
reduce and treat the injuries seen every year.
Like many states, Massachusetts has problems putting
certified Athletic Trainers in every high school due to
budget constraints.

Many schools have low athletic budgets

and cannot afford to hire certified Athletic Trainers.
Having a certified Athletic Trainer in a high school could
help to reduce hospital visits because they can provide the
appropriate care to student-athletes.

While the initial

hire of a certified Athletic trainer can cost a substantial
amount for a high school, costs can be reduced in the long

56
run by providing athletic health care services free of
charge on campus that were previously performed off campus
and for a fee.30,31

Schools that currently employ certified

athletic trainers have been able to show cost savings of as
much as $70,000-$80,000/year to student-athletes and their
families by providing on campus athletic training services.
A certified Athletic Trainer is the most appropriate
medical professional to have on staff at a high school to
care for student-athletes.

57

Appendix B
The Problem

58
The Problem

Statement of the Problem
Every student-athlete should have an equal opportunity
to benefit from proper athletic health care when they are
faced with an injury.

In order to better serve student-

athletes, a certified Athletic Trainer should be employed
at every high school across the country.

Certified

Athletic Trainers have extensive backgrounds in sports
medicine techniques, are nationally certified, and can be a
vital addition to any high school athletic department.
There are a significant number of adolescents that are
participating in high school athletics and with that, there
will inevitably be a high number of injuries.

These

injuries should not be left to an untrained individual.
Certified Athletic Trainers are educated in providing
initial injury assessment, first aid, rehabilitation, and
can make return to play decisions.

High schools should

recognize the need for hiring medical personnel who can
provide effective athletic heath care for their studentathletes.

The purpose of this study is to examine the

factors influencing the availability of certified Athletic
Trainers in high schools in Massachusetts.

59
Definition of Terms
The following terms have been identified for the
purpose of this study:
1. Athletic heath care- health care that is provided to
athletes.
2. Certified athletic trainer- a sports medicine
professional who collaborates with physicians to
optimize patient and client activity and participation
in athletics, work, and life.1

These professionals

have received a minimum of a bachelor’s degree and
passed a national examination.
3. School divisional classification- based on the amount
of students where division IV is the smallest and
division I is the largest.

Basic Assumptions
There are several basic assumptions the researcher
will use during this study.
1. The subjects will respond honestly to the survey.
2. The survey will have content validity after being
reviewed by the panel of experts.
3. There will be a high rate of return because Athletic
Directors care about their school’s athletic health
care.

60
Limitations of the Study
The following are possible limitations of the study:
1. Only Massachusetts high school Athletic Directors are
participating in the study.
2. Some subjects may not respond to the survey.
3. The results will be restricted based on the questions
asked in the survey.

Significance of the Study
With the significant amount of high school studentathletes, injuries are bound to occur.

Certified Athletic

Trainers should be employed by every high school in order
to provide effective athletic health care to these studentathletes.

Factors such as school divisional classification

(I, II, III, IV), athletic budgets, and the number of
varsity sports at a high school may have an affect on
whether or not a certified Athletic Trainer is present at a
school.
Student-athletes deserve to have medical professionals
who are thoroughly educated in providing effective athletic
health care caring for them.

High schools need to

recognize the growing need for certified Athletic Trainers
at the high school level.

There is a high number of

physically active individuals in the United States and high

61
school athletics should not be overlooked as an area in
which sports medicine professionals such as certified
Athletic Trainers should be hired.

In Massachusetts like

many other states, there are no laws requiring certified
Athletic Trainers to work at every high school.

By

evaluating the factors which influence if a high school has
a certified Athletic Trainer or not, it should help
governing bodies improve laws and mandate certified
Athletic Trainers be hired at every high school in
Massachusetts.

62

Appendix C
Additional Methods

63

Appendix C1
Panel of Experts Letter

64
December 2010
Dear_______________:
I am a graduate athletic training student at California
University of Pennsylvania pursuing a Master of Science
degree in athletic training. To fulfill the thesis
requirement for this program, I am conducting a descriptive
study. The objective of this study is to determine the
factors that influence whether high schools have a
certified athletic trainer or not.
In order to increase the content validity of the
instrument, a panel of experts has been chosen to review
the survey. You have been selected as one of the three
professionals to be on this panel. Your feedback is vital
to the success of this study. The information obtained by
this panel of experts review will be used to make revisions
and create the final survey to be distributed to the
population sample. Your responses are voluntary and will
be confidential.
Please answer the following questions based on the attached
survey and make any other additional comments you deem
appropriate. Please return your comments and revisions via
email no later than ____. If you have any questions or
concerns, please do not hesitate to contact me.
1. Are the questions appropriate, valid, and
understandable? Please Explain.
2. Comment on the overall presentation of the survey.
3. Which questions, if any, should be restated from the
survey? Why? What suggestions would you make?
4. Which questions, if any, should be added to the
survey? Why? What suggestions would you make?

Thank you in advance for your time and efforts.
Sincerely,
Kathryn Annunziata, ATC
California University of Pennsylvania

65

Appendix C2
High School Certified Athletic Trainer Availability Survey

66
High School Certified Athletic Trainer Availability Survey

1.

Is there a certified Athletic Trainer employed at your
high school? Yes
No

2.

If your high school does not have a certified Athletic
Trainer, what medical professional provides athletic
health care to your student-athletes? Please check
all that apply.
Physician
Nurse
Physician’s Assistant
EMT
Coach
Physical Therapist
None
Other______________

3.

How many certified Athletic Trainers work at your high
school?_____________

4.

How long has your school employed a certified Athletic
Trainer?_____________

5.

Is your certified Athletic Trainer full-time or parttime? Full-time
Part-time

6.

If you have more than one certified Athletic Trainer,
identify the number of full-time and part-time
certified Athletic Trainers. Full-time
Part-time

7.

Approximately, how many hours a week do your certified
Athletic Trainer(s) work at your high school? ______

8.

If your high school does not have a certified Athletic
Trainer, please specify why not. Please check all that
apply.
Not enough money in budget
Total number of varsity sports
No affiliation with a local clinic
Care provided by other personnel
No place to house a certified Athletic Trainer
Other_____________________________

67
9.

Are you satisfied with the number of medical personnel
that provide athletic health care coverage to your
student-athletes?
Yes
No

10.

Is your high school public or private?
Public
Private

11.

What is the divisional classification of your high
school?
I
II
III IV
Other___________

12.

How many varsity boys’ sports does your high school
have?
_____________
Please indicate which varsity boys’ sports your high
school has. Please check all that apply:
Baseball
Basketball
Field Hockey
Football
Golf
Gymnastics
Ice Hockey
Lacrosse
Skiing

13.

Soccer
Swimming/Diving
Tennis
Indoor Track
Outdoor Track
Volleyball
Wrestling
Other____________

How many varsity girls’ sports does your high school
have?
_____________
Please indicate which varsity girls’ sports your high
school has. Please check all that apply:
Basketball
Field Hockey
Football
Golf
Gymnastics
Ice Hockey
Lacrosse

Soccer
Softball
Swimming/Diving
Tennis
Indoor Track
Outdoor Track
Volleyball

68
Skiing

14.

Which of these varsity sports have a certified
Athletic Trainer providing athletic health care
coverage during practices? Please check all that
apply.
Baseball
Boys Basketball
Girls Basketball
Boys Golf
Girls Golf
Boys Field Hockey
Girls Field Hockey
Football
Boys Gymnastics
Girls Gymnastics
Boys Ice Hockey
Girls Ice Hockey
Boys Lacrosse
Girls Lacrosse
Boys Skiing
Girls Skiing

15.

Wrestling
Other____________

Softball
Boys Soccer
Girls Soccer
Boys Swimming/Diving
Girls Swimming/Diving
Boys Tennis
Girls Tennis
Boys Indoor Track
Girls Indoor Track
Boys Outdoor Track
Girls Outdoor Track
Boys Wrestling
Girls Wrestling
Boys Volleyball
Girls Volleyball
Other____________
None

Which of these varsity sports have a certified
Athletic Trainer providing athletic health care
coverage during games? Please check all that apply.
Baseball
Boys Basketball
Girls Basketball
Boys Golf
Girls Golf
Boys Field Hockey
Girls Field Hockey
Football
Boys Gymnastics
Girls Gymnastics
Boys Ice Hockey
Girls Ice Hockey
Boys Lacrosse
Girls Lacrosse
Boys Skiing

Softball
Boys Soccer
Girls Soccer
Boys Swimming/Diving
Girls Swimming/Diving
Boys Tennis
Girls Tennis
Boys Indoor Track
Girls Indoor Track
Boys Outdoor Track
Girls Outdoor Track
Boys Wrestling
Girls Wrestling
Boys Volleyball
Girls Volleyball

69
Girls Skiing

16.

Other____________
None

What is the total athletic budget of your high school?
_____________

Please provide any additional comments:

Approved by the California University of Pennsylvania IRB

70

APPENDIX C3
Institutional Review Board
California University of Pennsylvania

71

72

73

74

75

76

77

78

79

80
IRB 10-034 approval
instreviewboard
Sent:Thursday, February 03, 2011 3:07 PM
To: ANN2828 - ANNUNZIATA, KATHRYN NICOLE
Cc: Biddington, Carol; Skwarecki, Robert
Institutional Review Board
California University of Pennsylvania
Psychology Department LRC, Room 310
250 University Avenue
California, PA 15419
instreviewboard@cup.edu
instreviewboard@calu.edu
Robert Skwarecki, Ph.D., CCC-SLP,Chair
Ms. Annunziata ,
Please consider this email as official notification that your proposal titled
“The Availability of Certified Athletic Trainers in High Schools in
Massachusetts” (Proposal #10-034) has been approved by the California
University of Pennsylvania Institutional Review Board as submitted.
The effective date of the approval is 02-03-2011 and the expiration date is
02-02-2012. These dates must appear on the consent form.
Please note that Federal Policy requires that you notify the IRB promptly
regarding any of the following:
(1) Any additions or changes in procedures you might wish for your
study (additions or changes must be approved by the IRB before
they are implemented)
(2) Any events that affect the safety or well-being of subjects
(3) Any modifications of your study or other responses that are
necessitated by any events reported in (2).
(4) To continue your research beyond the approval expiration date of
02-02-2012 you must file additional information to be considered
for continuing review. Please contact instreviewboard@calu.edu
Please notify the Board when data collection is complete.
Regards,
Robert Skwarecki, Ph.D., CCC-SLP
Chair, Institutional Review Board

81

APPENDIX C4
Cover Letter to Participants

82

Dear Participants:
I am a master’s degree candidate at California University
of Pennsylvania, requesting your help to complete part of
my degree requirements. There is a high number of studentathletes at the secondary school setting participating in
athletics and there needs to be a medical professional
readily available to them who is properly educated in
caring for athletic injuries. Certified Athletic Trainers
are trained to recognize and treat injuries sustained in
the athletic setting. The results of this study (not
including individual information) may be published in
medical journals to inform the medical community of the
factors that influence whether high schools in
Massachusetts employ a certified Athletic Trainer.
Massachusetts high school Athletic Directors have been
chosen as the subjects for this study because the
researcher feels they can accurately provide information
about their school’s athletic health care coverage. Please
follow the link at the end of this letter to an online
survey titled: High School Certified Athletic Trainer
Availability Survey.
The questionnaire consists of 16 questions, which will take
about 10 minutes to complete. Due to this being a survey
there is minimal risk involved as confidentiality will be
maintained.
All Massachusetts high school Athletic Directors are being
asked to complete this questionnaire, although you do have
the right to choose not to participate or to discontinue
participation at any time. If the participant chooses to
discontinue the survey (by clicking the EXIT THIS SURVEY
button on the top of the webpage) then all information will
be discarded. The California University of Pennsylvania
Institutional Review Board has approved this study for the
Protection of Human Subjects. This approval is effective
MM/DD/YEAR and expires MM/DD/YEAR.
This is an anonymous questionnaire and upon submission,
neither your name nor email address will be attached to
your answers. Your information will be kept strictly
confidential and it will only be accessible to the
researcher. All survey information will be stored on a
password protected online database that only the researcher
will have access to. Upon completion of the study all

83
individual survey results will be deleted. By completion
of the survey, you are giving the researcher consent to use
the results of your survey in the study.
As a Massachusetts high school Athletic Director, your
information and opinions regarding this topic makes your
input invaluable. Please take a few minutes to fill out
the anonymous questionnaire you will find by clicking on
this link:
LINK
If you have any concerns or questions please feel free to
contact me through email at Ann2828@calu.edu or by phone at
(203)444-1450. Thank you for your time and consideration.

Sincerely,

Kathryn Annunziata, ATC
California University of Pennsylvania
250 University Avenue
California, PA 15419
Ann2828@calu.edu
(203)444-1450

Carol Biddington, EdD
Faculty Advisor
Exercise Science and Sport Studies
Biddington@calu.edu
724-938-4356

84
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ABSTRACT
TITLE:

THE AVAILABILITY OF CERTIFIED ATHLETIC
TRAINERS IN HIGH SCHOOLS IN MASSACHUSETTS

RESEARCHER:

Kathryn Annunziata, ATC

ADVISOR:

Dr. Carol Biddington

PURPOSE:

To determine the number of certified
Athletic Trainers working at the secondary
school level in Massachusetts.

METHODS:

Massachusetts high school athletic directors
(N=44) were surveyed using
www.surveymonkey.com. The survey consisted
of 16 questions regarding certified Athletic
Trainers and athletic health care
availability to student-athletes in
Massachusetts high schools.

FINDINGS:

Division I high schools were more likely to
employ a certified Athletic Trainer than
divisions II, III, or IV schools. High
schools with more varsity boys’ and girls’
sports teams were more likely to have a
certified Athletic Trainer than schools with
less sports teams. Schools that indicated
larger athletic budgets were more likely to
have a certified Athletic Trainer than
schools with less financial means. Also,
the likelihood of certified Athletic Trainer
employment significantly improved with more
girls’ varsity sports. Finally, a majority
(54.1%) of hired certified Athletic Trainers
were part-time.

CONCLUSION:

After review of the results, it is concluded
that 56.8% of high schools in Massachusetts
have certified Athletic trainers available
to their student-athletes. Schools of all
sizes have begun to recognize the need for
certified Athletic Trainers at the secondary
school level. Many Athletic Directors
(54.5%) at high schools in Massachusetts are
satisfied with the athletic health care
provided to their student-athletes.