High School Athletes' Parents' Perceptions and Knowledge of the Skills and Job Requirements of the Certified Athletic Trainer

ContextParents play a crucial role in determining medical services for their children, and it is important they understand the scope of practice and skills of the athletic trainer (AT).ObjectiveTo understand parents'' perceptions and knowledge of the skills and job requirements of the secondary school AT.DesignCross-sectional study.SettingSport meetings and banquets at 5 high schools in southwest Michigan during the fall, winter, and spring seasons.ResultsOf the 539 parents who responded, 28% responded yes, and 72% responded no to having experience with an AT for their own injuries. When asked if they had experience with an AT due to their child''s injuries, 60% responded yes. We found a difference among the 3 categories of experience for perception scores (P = .002) and knowledge scores (P < .001).ConclusionsIn the absence of past experience with an AT, parents'' perceptions and knowledge of the skills and job requirements of the secondary school AT are limited. Athletic trainers should educate parents on their professional roles, which may enhance their ability to provide better health care.Key Words: secondary schools, awareness, guardians

Key Points

• Parents have varying perceptions of athletic trainers based upon past experiences.
• Parents view the athletic trainer as a valued member of the secondary school health care team.
• Parents who have limited past experience with athletic trainers rate emergency care as the primary job responsibility.

Over the past 20 years, secondary school sport participation among students in the United States has consistently increased.¹ To ensure the proper care of these athletes, the American Medical Association recommended that all secondary schools provide athletic training services.² In addition to the athletic trainer (AT), the National Athletic Trainers'' Association has recommended that an athletic health care team (AHCT) be established that includes an AT, school nurse, physician, and other health care professionals.^3,4 The AHCT''s primary purpose is to work with the athletic director, coaches, and parents to ensure that appropriate medical care is provided for all athletes.To work congruently in providing the best possible care for secondary school student-athletes, members of the AHCT, along with athletic directors, coaches, and parents, must understand the variety of responsibilities of the AT. Previous investigations^5–7 showed that physicians and administrators have a basic understanding of the roles of ATs, but conversely, coaches did not fully recognize the scope of the ATs'' credentials or certification requirements. Additionally, when emergency medical service personnel were questioned, they too showed an incomplete comprehension of ATs'' roles as health care providers, predominantly in sport-related emergency care.⁸ These investigations led to a general consensus on misconceptions of ATs'' roles and responsibilities, likely stemming from a lack of experience with an AT in a secondary school setting.Less studied but perhaps one of the most important groups affiliated with the health care of the secondary school athlete is parents. Parents had a basic idea of the roles of an AT but lacked full understanding of the athletic training profession.⁹ Because parents play a crucial part in determining medical services for their children in the secondary school setting, they must have a thorough understanding of the scope of practice and skills of ATs in order for their children to receive the best medical care possible. Therefore, the purposes of our study were to further investigate parents'' overall perceptions and knowledge of the secondary school AT and to determine whether parents'' past experiences with ATs influenced their overall perceptions and knowledge of the athletic training profession and professional practice domains.     

Methods of the National Collegiate Athletic Association Injury Surveillance Program, 2014–2015 Through 2018–2019

BackgroundSince 1982, the National Collegiate Athletic Association (NCAA) has collaborated with athletic trainers (ATs) to create the largest ongoing collegiate sports injury database in the world. This report provides an operational update of the NCAA Injury Surveillance Program (NCAA ISP) during the academic years 2014–2015 through 2018–2019.Surveillance system structureThe NCAA ISP used a convenience sampling technique via a rolling recruitment model. The ATs at contributing institutions voluntarily submitted data into their respective electronic medical record systems; common data elements were pushed to and maintained by the Datalys Center. The ATs provided information about all team-related activities, even if no injury occurred during that activity, as well as detailed reports on each injury, including condition and circumstances.SummaryThe NCAA ISP has a long-standing role in supplying NCAA stakeholders with crucial injury surveillance data, playing a critical part in safeguarding student-athletes participating in collegiate sports.     

Oncologists’ experiences caring for LGBTQ patients with cancer: Qualitative analysis of items on a national survey

ObjectivesSexual and gender minority (SGM) individuals experience cancer-related health disparities and reduced quality of cancer care compared to the general population in part due to a lack of knowledgeable providers. This study explored oncologists’ experiences and perspectives in providing patient-centered care for SGM individuals with cancer.MethodsWe conducted a qualitative analysis of oncologists’ responses to four open-ended items on a national survey eliciting their experiences, reservations, and suggestions in treating SGM patients.ResultsOver 50 % of the 149 respondents of the national survey responded to at least one open-ended item. Many oncologists reported positive experiences reflecting personal growth and affirmative care practices, such as open, non-judgmental communication, compassion, competence, and supporting patients’ identity. There was a notable lack of experience with transgender patients in particular. Lack of knowledge, interpersonal communication concerns (e.g., fear of offending patients), and microaggressions (“don’t ask, don’t tell”) were identified as barriers to providing affirming care.ConclusionsOncologists recognize their knowledge deficits and need strategies to overcome communication barriers and microaggressions among the cancer care team to provide SGM-affirming care.Practice implicationsCurricula are needed to train oncologists in SGM healthcare needs and affirming communication skills to facilitate patient-centered care for SGM individuals with cancer.     

Athletic trainers' attitudes toward lesbian, gay, and bisexual National Collegiate Athletic Association student-athletes

Context:

Researchers have investigated heterosexuals'' attitudes toward homosexuals, focusing on factors such as sex, race, religion, education, and contact experiences. However, in the context of sport, this research is deficient. We found no published literature investigating athletic trainers (ATs'') attitudes toward lesbian, gay, and bisexual student-athletes (LGB).

Objective:

To determine heterosexual ATs'' attitudes toward LGB student-athletes in the National Collegiate Athletic Association.

Design:

Cross-sectional study

Setting:

E-mailed survey.

Patients or Other Participants:

A total of 964 ATs employed at member institutions.

Main Outcome Measure(s):

We measured attitudes using the Attitudes Toward Lesbian, Gay Men, and Bisexuals (ATLGB) Scale. To determine the extent to which sex, religion, and whether having an LGB friend or family member had an effect on ATs'' attitudes, we performed analysis of variance. To establish the effect of age on ATs'' attitudes, we calculated a Pearson correlation. We used an independent t test to identify differences between ATs who reported working with LGB student-athletes and ATs who did not.

Results:

With ATLGB score as the dependent factor, a main effect was noted for sex, religion, and having an LGB friend or family member (P < .01 for all comparisons). Age and total score were related (P < .01). A difference was seen in the ATLGB scores between ATs who were aware of LGB student-athletes on their teams and ATs who were not (P < .001).

Conclusions:

Many ATs hold positive attitudes toward LGB student-athletes, especially females, those who have an LGB friend or family member, and those who are aware of LGB student-athletes. Still, it is important to provide an open environment in the athletic training room for all student-athletes.     

Methods of the National Athletic Treatment,Injury and Outcomes Network Surveillance Program (NATION-SP), 2014–2015 Through 2018–2019

BackgroundThe National Athletic Treatment, Injury and Outcomes Network Surveillance Program (NATION-SP) was established in 2011 to provide a comprehensive appraisal of injuries sustained by high school student-athletes who received services from athletic trainers (ATs). The purpose of this article is to update the surveillance methods of the NATION-SP for data reported during the 2014–2015 through 2018–2019 academic years.Surveillance System StructureThe NATION-SP used a rolling recruitment model to identify a convenience sample of US high schools with access to ATs. The ATs at participating institutions volunteered to contribute data via electronic medical records systems; common data elements were then pushed to and maintained by the Datalys Center for Sports Injury Research and Prevention. The ATs completed detailed reports on each injury, including the condition and circumstances. The treatments component was used to comprehensively assess the services provided to athletes by ATs. The outcomes companion component was developed to monitor patient-reported outcomes after athletic injury.SummaryThe NATION-SP continues to serve a critical purpose in informing injury-prevention and treatment efforts among high school athletes.     

The importance of state regulation to the promulgation of the athletic training profession

States regulate professions to protect the public from harm by unqualified practitioners. Without regulation of athletic trainers (ATs), there is no legal way to assure quality health care to athletes because there is no legal definition as to what an AT can and cannot do. Problems exist, however; 1) ATs nationwide may not be adequately familiar with state regulations; 2) without regulation, legal support is given to high schools to use less qualified persons to care for student-athletes; 3) more education is needed to familiarize the public and the health care industry with the functions and qualifications of a certified AT; and 4) without uniformity of regulation, athletes may continue to suffer as untrained and/or unqualified persons continue to be perceived as members of the profession and as certified and noncertified ATs continue to practice without legal sanction, perhaps beyond their area of expertise. This article encompasses both a literature review and an opinion survey (of ATs) with regard to state regulation of the athletic training profession. The intent of this article is to help ATs understand the implications of state regulation on our profession. A survey was mailed to 500 ATs across the country soliciting opinions on state regulation and its implication of the profession of athletic training. The intent of the survey results are not to verify the literature review nor to infer information regarding other ATs, but merely to be a gathering tool to solicit information from fellow ATs.     

Practice Patterns of Athletic Trainers Regarding the On-Site Management of Patients With Joint Dislocations

ContextAs part of clinical practice, athletic trainers (ATs) provide immediate management of patients with acute joint dislocations. Management techniques may include on-site closed joint reduction of the dislocated joint. Although joint reduction is part of the 2020 educational standards, currently practicing ATs may have various levels of exposure, knowledge, and skills.ObjectiveTo capture AT self-reported knowledge and practice patterns concerning closed joint reductions.DesignCohort study.SettingOnline survey (Qualtrics).Patients or Other ParticipantsThe survey link was emailed to 5000 certified ATs. A total of 772 responses were completed by certified ATs with clinical practice experience (15.4% response rate).Main Outcome Measure(s)Participants were asked to complete a survey about their practice patterns concerning patients with closed joint reductions, which included questions about the types of closed reductions ATs performed most commonly, the frequency of on-site reduction by ATs, and participants'' demographic information. Additionally, the survey addressed the ATs'' training and comfort level in performing closed reductions and knowledge of standing orders and the state practice act.ResultsNinety percent (n = 694) of ATs reported ever performing a closed reduction (either with or without a physician present), with 10% (n = 78) stating they had never performed a joint reduction. The interphalangeal joint of the finger (73.2% of ATs), shoulder (63.3%), and patella (48.2%) were cited as the 3 most common reductions performed without a physician present. Only 46.5% (n = 359) of ATs indicated receiving training in joint-reduction techniques as part of their precertification athletic training curriculum or program; a greater percentage (64%) said they learned directly from a physician. Fewer than 60% of ATs reported having standing orders related to joint reductions.ConclusionsConsidering the high percentage of ATs who reported performing closed joint reductions and the low percentage with formal training, further development of joint-reduction training and standing orders is warranted.     

Exploring the Athletic Trainer's Role in Assisting Student-Athletes Presenting With Alcohol-Related Unintentional Injuries

Compared with their nonathlete peers, collegiate athletes consume higher quantities of alcohol, drink with greater frequency, and exhibit an increased propensity to engage in heavy episodic drinking (ie, binge drinking), which often may result in alcohol-related consequences. Moreover, collegiate athletes are also more likely to engage in other maladaptive lifestyle behaviors, such as participating in physical fights and riding with an intoxicated driver, and less likely to engage in protective behaviors, such as wearing a helmet while operating a motorcycle, moped, or bicycle. Taken together, these behaviors clearly pose a health risk for student-athletes and increase the likelihood that they will experience an alcohol-related unintentional injury (ARUI). An ARUI represents a risk not only to the health and well-being of collegiate athletes but also to their athletic performances, collegiate careers, and potential professional opportunities. Therefore, athletic trainers need to be equipped with the knowledge and skills to provide face-to-face brief interventions to student-athletes presenting with ARUIs and to evaluate the effect of their involvement. We address potential action items for implementation by athletic trainers.Key Words: collegiate athletes, alcohol use, alcohol-related consequences, interventionsCompared with their nonathlete peers, collegiate athletes consume higher quantities of alcohol, drink with greater frequency, and exhibit increased propensities to engage in heavy episodic drinking (ie, binge drinking).^1–3 Given their high-risk drinking behaviors, student-athletes are more likely to experience alcohol-related consequences.^4,5 Compared with nonathletes, collegiate athletes also are more likely to engage in other maladaptive lifestyle behaviors, such as participating in physical fights and riding with an intoxicated driver, and less likely to engage in protective behaviors, such as wearing a helmet while operating a motorcycle, moped, or bicycle.⁶ Taken together, these behaviors clearly pose a health risk for student-athletes and increase the likelihood that they will experience alcohol-related unintentional injuries (ARUIs). An ARUI represents a risk not only to the health and well-being of collegiate athletes but also to their athletic performances, collegiate careers, and potential professional opportunities. Head athletic trainers (ATs) contend that alcohol abuse during and after athletic and social events continues to be an important concern for the health and safety of student-athletes.⁷In a recent cross-sectional study, Brenner et al⁸ observed that, overall, approximately 18% of collegiate athletes experienced ARUIs and most of these occurred during the athletes'' first and second years in school. Furthermore, they noted that 38% of collegiate athletes identified ARUI as a serious issue facing them.⁸ Moreover, approximately 56% of ATs recently reported that during the 2010–2011 academic year, they evaluated, treated, or referred an average of 3 ARUIs, most of which (63%) were classified as either moderate or severe.⁹Not surprisingly, Brenner et al⁹ observed that most ATs (73.4%) assert that ARUIs are a serious problem affecting the health of collegiate athletes, with 65.7% believing that they should be involved in the alcohol-related screening process for student-athletes. In addition, Brenner et al reported that most ATs contend that more training is necessary to help them (1) identify student-athletes with ARUIs (79%), (2) confront student-athletes with alcohol-related problems (79.7%), and (3) involve themselves in the referral process (92%).⁹ Furthermore, most head ATs have also expressed interest in becoming more involved with alcohol intervention programs.⁷ Considering that most university ATs already are substantially involved with regularly evaluating and treating non–alcohol-related injuries among student-athletes, ATs can and should play important roles in recognizing and evaluating ARUIs among student-athletes, especially given their expressed desire for more training in the intervention, prevention, and referral of ARUIs. Furthermore, ATs view themselves as “safe, approachable, care-taking individuals with whom athletes felt comfortable disclosing personal information,”¹⁰(p150) placing them in a unique position to provide appropriate intervention when necessary.     

Adoption of Lightning Safety Best-Practices Policies in the Secondary School Setting

ContextLightning-related injuries are among the top 10 causes of sport-related death at all levels of sport, including the nearly 8 million athletes participating in US secondary school sports.ObjectiveTo investigate the adoption of lightning safety policies and the factors that influence the development of comprehensive lightning safety policies in United States secondary schools.DesignCross-sectional study.SettingSecondary school.Patients or Other ParticipantsAthletic trainers (ATs).Main Outcome Measure(s)An online questionnaire was developed based on the “National Athletic Trainers'' Association Position Statement: Lightning Safety for Athletics and Recreation” using a health behavior model, the precaution adoption process model, along with facilitators of and barriers to the current adoption of lightning-related policies and factors that influence the adoption of lightning policies. Precaution adoption process model stage (unaware for need, unaware if have, unengaged, undecided, decided not to act, decided to act, acting, maintaining) responses are presented as frequencies. Chi-square tests of associations and prevalence ratios with 95% CIs were calculated to compare respondents in higher and lower vulnerability states, based on data regarding lightning-related deaths.ResultsThe response rate for this questionnaire was 13.43% (n = 365), with additional questionnaires completed via social media (n = 56). A majority of ATs reported maintaining (69%, n = 287) and acting (6.5%, n = 27) a comprehensive lightning safety policy. Approximately 1 in 4 ATs (25.1%, n = 106) described using flash to bang as an evacuation criterion. Athletic trainers practicing in more vulnerable states were more likely to adopt a lightning policy than those in less vulnerable states (57.4% versus 42.6%, prevalence ratio [95% CI] = 1.16 [1.03, 1.30]; P = .009). The most commonly cited facilitator and barrier were a requirement from a state high school athletics association and financial limitations, respectively.ConclusionsA majority of ATs related adopting (eg, maintaining and acting) the best practices for lightning safety. However, many ATs also indicated continued use of outdated methods (eg, flash to bang).     

Self-Reported Health and Fitness Habits of Certified Athletic Trainers

Context:

As health care providers, certified athletic trainers (ATs) should be role models for healthy behaviors.

Objective:

To analyze the self-reported health and fitness habits of ATs.

Design:

A cross-sectional, cluster random sample.

Setting:

Online questionnaire.

Patients or Other Participants:

Of a sampling frame of 1000 potential participants, 275 ATs completed the questionnaire.

Main Outcome Measure(s):

Health habits and activity were based on a typical 7-day week.

Results:

A total of 41% of the participants met the exercise recommendations of the American College of Sports Medicine; 7% reported being sedentary. Differences were noted between the sexes for fitness habits (P < .035) and composite health score (P < .001). None of the ATs reported meeting the Daily Reference Intake for all 5 food groups. Seven percent of female ATs consumed more alcohol than recommended, compared with 2% of males. However, 80% of males and 93% of females reported consuming 5 or fewer drinks per week. Only 0.8% reported currently smoking.

Conclusions:

This sample of ATs had better health and fitness habits than the general population but did not meet professional recommendations set forth by the American College of Sports Medicine or the United States Department of Agriculture. Thus, these ATs were not ideal role models in demonstrating healthy behaviors.     

Energy Balance,Eating Disorder Risk,and Pathogenic Behaviors Among Athletic Trainers

ContextResearch exists on energy balances (EBs) and eating disorder (ED) risks in physically active populations and occupations by settings, but the EB and ED risk in athletic trainers (ATs) have not been investigated.ObjectiveTo assess ATs'' energy needs, including the macronutrient profile, and examine ED risk and pathogenic behavioral differences between sexes (men, women) and job statuses (part time or full time) and among settings (college or university, high school, nontraditional).DesignCross-sectional study.SettingFree living in job settings.Patients or Other ParticipantsAthletic trainers (n = 46; male part-time graduate assistant ATs = 12, male full-time ATs = 11, female part-time graduate assistant ATs = 11, female full-time ATs = 12) in the southeastern United States.Main Outcome Measure(s)Anthropometric measures (sex, age, height, weight, body composition), demographic characteristics (job status [full- or part-time AT], job setting [college/university, high school, nontraditional], years of AT experience, exercise background, alcohol use), resting metabolic rate, energy intake (EI), total daily energy expenditure (TDEE), EB, exercise energy expenditure, macronutrients (carbohydrates, protein, fats), the Eating Disorder Inventory-3, and the Eating Disorder Inventory-3 Symptom Checklist.ResultsThe majority of participants (84.8%, n = 39) had an ED risk, with 26.1% (n = 12) engaging in at least 1 pathogenic behavior, 50% (n = 23) in 2 pathogenic behaviors, and 10.8% (n = 5) in >2 pathogenic behaviors. Also, 82.6% of ATs (n = 38) presented in negative EB (EI < TDEE). Differences were found in resting metabolic rate for sex and job status (F_1,45 = 16.48, P = .001), EI (F_1,45 = 12.01, P = .001), TDEE (F_1,45 = 40.36, P < .001), and exercise energy expenditure (F_1,38 = 5.353, P = .026). No differences were present in EB for sex and job status (F_1,45 = 1.751, P = .193); χ² analysis revealed no significant relationship between ATs'' sex and EB (= 0.0, P = 1.00) and job status and EB ( = 2.42, P = .120). No significant relationship existed between Daily Reference Intakes recommendations for all macronutrients and sex or job status.ConclusionsThese athletic trainers experienced negative EB, similar to other professionals in high-demand occupations. Regardless of sex or job status, ATs had a high ED risk and participated in unhealthy pathogenic behaviors. The physical and mental concerns associated with these findings indicate a need for interventions targeted at ATs'' health behaviors.     

Impact of an Online Medical Internet Site on Knowledge and Practice of Health Care Providers: A Mixed Methods Study of the Spinal Cord Injury Rehabilitation Evidence Project

BackgroundIt is not known whether ongoing access to a broad-based Internet knowledge resource can influence the practice of health care providers. We undertook a study to evaluate the impact of a Web-based knowledge resource on increasing access to evidence and facilitating best practice of health care providers.ObjectiveThe objective of this study was to evaluate (1) the impact of the Spinal Cord Injury Rehabilitation Evidence (SCIRE) project on access to information for health care providers and researchers and (2) how SCIRE influenced health care providers'' management of clients.MethodsA 4-part mixed methods evaluation was undertaken: (1) monitoring website traffic and utilization using Google Analytics, (2) online survey of users who accessed the SCIRE website, (3) online survey of targeted end-users, that is, rehabilitation health care providers known to work with spinal cord injury (SCI) clients, as well as researchers, and (4) focus groups with health care providers who had previously accessed SCIRE.ResultsThe online format allowed the content for a relatively specialized field to have far reach (eg, 26 countries and over 6500 users per month). The website survey and targeted end-user survey confirmed that health care providers, as well as researchers perceived that the website increased their access to SCI evidence. Access to SCIRE not only improved knowledge of SCI evidence but helped inform changes to the health providers’ clinical practice and improved their confidence in treating SCI clients. The SCIRE information directly influenced the health providers’ clinical decision making, in terms of choice of intervention, equipment needs, or assessment tool.ConclusionsA Web-based knowledge resource may be a relatively inexpensive method to increase access to evidence-based information, increase knowledge of the evidence, inform changes to the health providers’ practice, and influence their clinical decision making.     

Assessment of Certified Athletic Trainers' Levels of Cultural Competence in the Delivery of Health Care

Context:

The concept of culture and its relationship to athletic training beliefs and practices is virtually unexplored. The changing demographics of the United States and the injuries and illnesses of people from diverse backgrounds have challenged health care professionals to provide culturally competent care.

Objective:

To assess the cultural competence levels of certified athletic trainers (ATs) in their delivery of health care services and to examine the relationship between cultural competence and sex, race/ethnicity, years of athletic training experience, and National Athletic Trainers'' Association (NATA) district.

Design:

Cross-sectional survey.

Setting:

Certified member database of the NATA.

Patients or Other Participants:

Of the 13 568 ATs contacted, 3102 (age  =  35.3 ± 9.41 years, experience  =  11.2 ± 9.87 years) responded.

Data Collection and Analysis:

Participants completed the Cultural Competence Assessment (CCA) and its 2 subscales, Cultural Awareness and Sensitivity (CAS) and Cultural Competence Behavior (CCB), which have Cronbach alphas ranging from 0.89 to 0.92. A separate univariate analysis of variance was conducted on each of the independent variables (sex, race/ethnicity, years of experience, district) to determine cultural competence.

Results:

The ATs'' self-reported scores were higher than their CCA scores. Results revealed that sex (F_1,2929  =  18.63, P  =  .001) and race/ethnicity (F_1,2925  =  6.76, P  =  .01) were indicators of cultural competence levels. However, we found no differences for years of experience (F_1,2932  =  2.34, P  =  .11) or NATA district (F_1,2895  =  1.09, P  =  .36) and cultural competence levels.

Conclusions:

Our findings provide a baseline for level of cultural competence among ATs. Educators and employers can use these results to help develop diversity training education for ATs and athletic training students. The ATs can use their knowledge to provide culturally competent care to athletes and patients and promote a more holistic approach to sports medicine.     

Athletic Directors' Barriers to Hiring Athletic Trainers in High Schools

ContextIn its best-practices recommendation, the Inter-Association Task Force for Preventing Sudden Death in Secondary School Athletics Programs urged all high schools to have a certified athletic trainer (AT) on staff. Despite the recommendation, many high schools lack the medical services of an AT.ObjectiveTo examine the barriers that athletic directors (ADs) face in hiring ATs in public high schools and in providing medical coverage for their student-athletes.DesignQualitative study.SettingSemistructured telephone interviews.ResultsWe identified 3 themes. Lack of power represented the inability of an AD to hire an AT, which was perceived to be a responsibility of the superintendent and school board. Budget concerns pertained to the funding allocated to specific resources within a school, which often did not include an AT. Nonbudget concerns represented rural locations without clinics or hospitals nearby; misconceptions about the role of an AT, which led to the belief that first-aid–trained coaches are appropriate medical providers; and community support from local clinics, hospitals, and volunteers.ConclusionsMany ADs would prefer to employ ATs in their schools; however, they perceive that they are bound by the hiring and budgeting decisions of superintendents and school boards. Public school systems are experiencing the consequences of national budget cuts and often do not have the freedom to hire ATs when other school staff are being laid off.Key Words: medical care, secondary school, staffing

Key Points

• Budgeting concerns influenced the decisions of athletic directors about employing athletic trainers.
• The athletic director is only 1 member of the administration who can influence the hiring of athletic trainers.
• Misconceptions regarding the value and role of the athletic trainer in the secondary school setting were barriers to hiring.

Researchers have estimated that more than 7 million high school students currently participate in organized sports.¹ Approximately 1.4 million sport-related injuries occur among high school athletes each year.² American football alone has been projected to produce 12.04 injuries per 1000 exposures during competitions and 2.54 injuries per 1000 exposures during practices.³ Whereas most athletic injuries are relatively minor, potentially limb-threatening or life-threatening emergencies can occur. One medical emergency that can affect athletes is exertional heat stroke, which is consistently among the top 3 causes of death in sport.⁴ On October 12, 2010, Tyler Davenport died of exertional heat stroke that occurred during a football practice in August (Douglas J. Casa, oral communication, June 3, 2014). Although Davenport''s coaches provided assistance at practice before transporting him to the hospital, their level of emergency medical training was limited to basic emergency care and focused on cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) training. Several deaths are reported each year, and they often result from a failure to recognize or implement appropriate care.⁵ Prompt and appropriate management of these injuries is critical to the patient''s outcome and should be carried out by trained health care personnel, such as a certified athletic trainer (AT), to minimize the risk of further injury or death.⁶The Inter-Association Task Force for Preventing Sudden Death in Secondary School Athletics Programs urged all high schools to have an AT on staff to take charge of emergency situations and provide care for student-athletes.^7,8 The AT can evaluate and properly treat injuries, including sprains, strains, contusions, and abrasions, as well as more serious conditions, such as exertional heat stroke and hyponatremia. The AT can also facilitate and manage athletic health care at the high school, referring as needed and treating many patients in house. The presence of an AT can help reduce health care costs for the school and for the parents of student-athletes. In addition to heat illnesses, emergencies involving asthma, brain and cervical spine injuries, diabetes, sudden cardiac death, exertional illnesses, and environmental dangers have resulted in the deaths of athletes of all ages.⁴ In 1994, only 35% of high schools used the services of an AT, and in 1997, only 13 states reported employing ATs in greater than 50% of high schools.⁹ By 2009, the national average of schools employing ATs had risen to only 42%.¹⁰ Whereas the prevalence of ATs in high schools is improving, some high schools still lack the appropriate medical personnel to institute guidelines for preventing sudden death in youth athletics.¹¹ In these settings, the responsibility to save young athletes may fall to coaches, athletic directors (ADs), or bystanders who are not trained in discerning similar signs and symptoms of potentially fatal circumstances.⁷ Specific and prompt care is critical for a patient to have the best chance of a positive outcome. In some situations, waiting until emergency medical services arrive to provide care can result in catastrophic injury or death, as demonstrated in Davenport''s case. Having onsite medical coverage provided by an AT can in many cases reduce the number of deaths that occur in high school athletes; yet in some cases, an AT is not available to provide such care.The importance of having an AT onsite has been well documented by various outlets but most prominently in the best-practices recommendation of the Inter-Association Task Force for Preventing Sudden Death in Secondary School Athletics Programs.^7,8 However, many high schools do not meet this recommendation. The Collaboration for Athletic Training Coverage in High Schools–An Ongoing National Study (CATCH-ON) provided preliminary data on the prevalence of ATs in public high schools across the United States; this study was designed to gain a better understanding of the medical coverage provided by US high schools.¹¹ After attempting to contact every public high school in the United States, the researchers observed that 70% of public high schools, which account for 86% of all student-athletes at this level, have some access to an AT. As part of the CATCH-ON project, initial data emerged about reasons for not having an AT.¹¹ Those barriers included budgetary concerns and the belief that an AT was not needed, mostly due to the CPR, AED, and first-aid training of coaches.¹¹ Therefore, the purpose of our study was to focus on the barriers that ADs face in providing medical coverage for their student-athletes and hiring ATs for public high schools. By examining these barriers more thoroughly, we hoped to find ways to help ADs initiate positive change by seeking AT coverage.