Athletic Training Services in Japan: A Comparison of the United States and Japan Based on Educational Background

Data Analysis

The JMP Pro (version 14.0; SAS Institute, Cary, NC), a statistical software package, was used for statistical analysis. Descriptive statistics were calculated to report demographic and background information. Calculations performed for descriptive data were based on the number of responses per question because responses to some of the questions were missing. We examined whether differences existed in (1) demographic characteristics, (2) educational characteristics, and (3) professional characteristics between BOC-ATs and JSPO-ATs (Table 1) using Pearson's χ² test. Analysis pertaining to licenses and credentials held by ATs was conducted using Fisher's exact test due to the limited number of samples in some cells. Statistical significance was set at P < .05.

Table 1 Variables Collected in the Survey

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Demographic Characteristics

Both JSPO-ATs and BOC-ATs in Japan were predominantly male (JSPO-ATs = 81.3%, BOC-ATs = 70.3%); however, the relative representation of female ATs was greater in BOC-ATs (29.7%) than in JSPO-ATs (18.7%; χ² [1] = 4.5, P = .03). More than 80% of BOC-ATs who answered the survey were 36 years old or older. In contrast, more than half of JSPO-ATs who answered the survey were 35 years old or younger (51.2%; Table 2).

Table 2 Comparison of Sex and Age Group of Japanese Athletic Trainers by Athletic Training Credentials

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Comparison of Educational Characteristics

A comparison of educational characteristics between BOC-ATs and JSPO-ATs is summarized in Table 3. Regarding the highest level of education, half of JSPO-ATs selected other, whereas none of the BOC-ATs chose this category. On the other hand, the largest group for BOC-ATs selected a master's degree (46.9%) as their highest level of education, and more than half of BOC-ATs reported having a master's degrees or higher (χ² [3] = 81.6, P < .01).

Table 3 Comparison of Educational Characteristics of Japanese Athletic Trainers by Athletic Training Credentials

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The number of respondents with therapist or medical practitioner licenses in Japan was greater for JSPO-ATs than for BOC-ATs in all categories (acupuncture, moxibustion, amma-massage-shiatsu, judo therapy, physical therapy; P < .05). The percentage of respondents with at least 1 therapist or medical practitioner license in Japan was 73.1% for JSPO-ATs, whereas only 20.3% of BOC-ATs met the criteria (P < .01).

Statistical differences in the proportion of respondents with the following 3 exercise science-related certifications were found between BOC-ATs and JSPO-ATs: Certified Strength and Conditioning Specialist (CSCS), National Academy of Sports Medicine Performance Enhancement Specialization (NASM-PES), and National Academy of Sports Medicine Corrective Exercise Specialization (NASM-CES). More BOC-ATs reported to be CSCS or CSCS*D (28.1%) than JSPO-ATs (P < .01). Similarly, more BOC-ATs reported having NASM-PES and NASM-CES than JSPO-ATs (NASM-PES: BOC-ATs = 35.9%, JSPO-ATs = 6.3%, P < .01; NASM-CES: BOC-ATs = 35.9%, JSPO-ATs = 0.1%, P < .01). The percentage of respondents with at least 1 credential in exercise, nutrition, or teaching in Japan was 62.5% for BOC-ATs, whereas 45.2% of JSPO-ATs met the criteria (P < .01).

Professional Characteristics

Statistical differences were observed between BOC-ATs and JSPO-ATs in all professional characteristics (P > .05; Table 4). For both groups, 11–20 years of experience was the most frequently reported category (BOC-AT = 50%, JSPO-AT = 30.5%). However, the overall trend differed between the groups (χ² [5] = 28.8, P < .01); more than half of JSPO-AT respondents (56%) reported having 10 years or less experience as an AT, whereas only 23.5% of BOC-AT respondents had 10 years or less experience.

Table 4 Comparison of Professional Characteristics of Japanese Athletic Trainers by Athletic Training Credentials

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The most common employment type for BOC-ATs was full time (54.7%), whereas part time was the largest group for JSPO-ATs (43.9%). Additionally, less than 1% of BOC-ATs classified their employment type as volunteer, whereas 17.7% of JSPO-ATs reported that they work as volunteers (χ² [3] = 32.3, P < .01).

The most common work setting for both groups was the elite level (BOC-ATs = 51.9%, JSPO-ATs = 46.3%). The second largest group was the university level for BOC-ATs (26.9%), whereas organized school sports was the second largest for JSPO-ATs (32.8%; χ² [3] = 10.4, P = .02).

The majority of JSPO-ATs (62.5%) and BOC-ATs (50.5%) identified themselves as ATs. However, a significant difference was observed in the proportion of individuals who identified themselves as therapists (JSPO-ATs = 29.8%, BOC-ATs = 6.3%; χ² [5] = 18.9, P < .01). Head AT or head athletic therapist was the most frequently reported job title by BOC-ATs (31.3%), whereas AT or athletic therapist was the most frequently reported for JSPO-ATs (35.2%). Significant differences were observed in educator (BOC-ATs = 20.3%, JSPO-ATs = 10.7%) and allied health care professional (BOC-AT = 4.7%, JSPO-AT = 17.8%; χ² [6] = 27.8, P < .01).

The median income category for BOC-ATs was 401–600 million yen (US$36 500–$54 500), whereas the median income category for JSPO-ATs was 0–200 million yen (US$0–$18 200). More than half of JSPO-ATs make less than 200 million yen (US$18 200), whereas 31.8% of BOC-ATs selected this category (χ² [4] = 32.4, P < .01).

Demographic Characteristics

Although both groups had greater representations of males than females, the proportion of female ATs was larger for BOC-ATs (29.7%) than for JSPO-ATs (18.7%), which may be associated with the greater percentage of female student representation in athletic training programs in the United States than in Japan. Furthermore, 80% (n = 667) of study participants (BOC-ATs and JSPO-ATs combined) were male, which differs greatly from what was reported by NATA in their April 2019 NATA Membership by Ethnicity and Gender Data, which showed that 43.9% of the NATA members in the United States registered in their survey were male.¹¹ This result may have been influenced by the strong propensity for Japanese society to perceive sports-related professions as a male-dominated field. Similarly, the numbers of female professional sport leagues are much fewer than those of male sports, which may also influence the number of positions available for female ATs. These social factors might result in fewer opportunities for female students to pursue a career as an AT.

The comparison by age group revealed that BOC-ATs were older than JSPO-ATs, which may be influenced by 2 factors. One is the age of the participants who received athletic training education. Japanese BOC-ATs tend to have completed a bachelor's degree in Japan before studying abroad in the United States. Before the entry-level master's programs became popular, these individuals went on to pursue another undergraduate program to study athletic training, which may have raised the average age of BOC-ATs in Japan. On the other hand, the youngest possible age for JSPO-ATs is 20 because some institutions offer a 2 year athletic training education program approved by JSPO. Another possible explanation is the organizational differences between JATO and JSPO. The JATO is a professional membership organization, whereby members must actively join the organization and pay the membership fee to maintain its benefits. For this reason, young certified BOC-ATs tend to opt out for various reasons (ie, cost, not seeing the benefits of a professional organization). On the other hand, the JSPO is an accreditation and credentialing organization, not a membership organization. Therefore, the JSPO was able to send the survey to all JSPO-certified ATs, including recent graduates.

Educational Characteristics

A greater proportion of BOC-ATs had higher levels of education compared to JSPO-ATs. It should be noted that the difference observed in the highest level of education received between JSPO-ATs and BOC-ATs is likely due to differences in the education and credentialing systems. Approximately half the JSPO-AT respondents answered other on the question about level of education, which included diplomas from high schools or vocational schools. Those with high school diplomas are likely the few individuals who were grandfathered into the system at the adoption of domestic accreditation programs in 1994. Currently, the JSPO offers 2 routes to become eligible for their certification exam. The first option is the seminar route, in which the JSPO enrolls approximately 100 candidates every year who already have some experience working in athletic settings as an AT. Seminar participants will complete educational courses offered by the JSPO to become eligible to take the JSPO-AT certification exam. The other option is the approved education program route, which is typically housed within educational institutions that have programs in the area of sports science. Currently, the JSPO does not require the candidate to have a bachelor's degree or the approved educational institution to be a 4 year college. In fact, 32 of the 68 JSPO-approved athletic training education programs are offered by vocational schools that do not offer college diplomas and usually require 2 to 3 years to complete.¹² Consequently, there is a mix of JSPO-ATs who have completed a university degree (51.4%) and others (high school and vocational school; 48.6%). On the other hand, all BOC-ATs had some level of university degree, with the greatest proportion of participants indicating a master's degree as their highest level of education completed. Since its establishment, the BOC credentialing ATs in the United States has set the bachelor's degree as the minimum level of education, with the majority of BOC-ATs pursuing graduate degrees. With the upcoming changes in 2022 to raise the minimum degree requirement to a master's degree, an additional change in the highest level of education among BOC-ATs may occur in the near future.¹³

The differences in educational characteristics may have also influenced the greater percentage of ATs with therapist licensure among JSPO-ATs than BOC-ATs, whereas the opposite relationship was observed in the proportion of ATs who hold exercise-related credentials. Many of the Japanese ATs who were grandfathered in were working as therapists, with their respective licensure in the field of health care. Their backgrounds as therapists provided educational and legal basis for providing therapy to athletes, but they only studied athletic training informally. This trend of Japanese ATs with therapist licensure continues, even after the JSPO-AT program was established. Among the 32 vocational schools offering JSPO athletic training education programs, 20 offer therapist education programs, such as acupuncture, massage therapy, and judo therapy. The education and credentialing programs for therapists are regulated by the Ministry of Health and Labor and do not have to follow the structure of 4 year collegiate degree programs. Some of these therapist education programs now offer courses in which students may choose a double major in the respective therapist course and a JSPO-approved education program.

Professional Characteristics

For professional characteristics, we found more BOC-ATs work as athletic training professionals compared to JSPO-ATs, which was confirmed by the findings pertaining to employment type, work setting, position, and job title. We believe that this difference in professional characteristics is influenced by differences in educational characteristics between the 2 groups. For example, a greater proportion of BOC-ATs worked in academic settings or served in higher roles (eg, head AT), which may be associated with the fact that a greater proportion of BOC-ATs had higher levels of education compared to JSPO-ATs. On the other hand, a greater proportion of JSPO-ATs chose therapist as a self-identified profession and allied health care professional for job title, which may be associated with the fact that a greater proportion of JSPO-ATs had educational background as a therapist. Furthermore, other factors such as the evolvement of athletic training as an extension of other existing licensed therapists, lack of social recognition, and limited financial support for ATs in Japan, may have contributed to the difference in professional characteristics.

For example, ATs in Japan may perceive that a licensed therapist will provide firmer legal status than only being certified as an AT because ATs are not regulated health care professionals in Japan. Often, an employer requires an AT to have some kind of therapist license in order for him or her to fulfill the responsibility of providing therapeutic interventions. In fact, three-fourths of full-time ATs held at least 1 therapist licensure.¹⁴ Second, the job expectations of an AT may be heavily weighted toward therapeutic interventions because that was the major role of traditional trainers in Japan.¹ Japanese traditional therapy, such as acupuncture and amma-massage-shiatsu therapy, are often the choice of therapeutic interventions for athletic health care. In fact, 38% of JSPO-AT respondents had acupuncture or moxibustion licensure in our study. Lastly, the lack of social recognition regarding the values of ATs affects the number of AT positions available and leads to less than ideal income for ATs. Financial resources for athletic training programs in Japan for Japanese sport teams are very limited, which necessitates ATs to make a living from multiple team appointments or other jobs. Our data found that 30% of JSPO-ATs work as therapists, but when asked about their employment type for their AT job, the most popular answers were part-time capacity. This may support the previous point about the high proportion of JSPO-ATs with therapist licensure because these individuals may choose to work as therapists in clinics and hospitals for a living while still providing athletic training services as part-time ATs. Contrarily, we found exercise-related credentials to be more popular among BOC-ATs, who may have been exposed to nontherapeutic areas of athletic training during their time in the United States. Such differences in background may be associated with the finding that more BOC-ATs were working as strength and conditioning coaches or trainers and personal trainers than JSPO-ATs.

Evolution of Athletic Training in Japan and the Future

It has been more than 25 years since the establishment of the JSPO athletic training education and credentialing system. Due to the differences in historical and regulatory backgrounds, the evolution of athletic training in Japan has taken a different path from that of the United States in some ways. For example, by the time athletic training was introduced in Japan, traditional trainers with various backgrounds were already providing care for athletes. Consequently, the introduction of athletic training further diversified our approach to athletic health care and created political challenges. Therefore, the inception of the JSPO-AT education and credentialing system aimed to create a common ground for existing therapists and future ATs. Thus, the Japanese AT education and credentialing system was not designed to produce licensed health care providers but rather serve to set the minimum standard for ATs in Japan.

Nevertheless, athletic training in the United States faced similar growing pains during the initial development phase of their primary AT organization. For example, during the early years, obtaining a health or physical education teaching license or physical therapy license was encouraged in the United States, but NATA spent many years and great effort to have ATs recognized as allied health care professionals by the American Medical Association in 1991, which greatly contributed to increasing the regulatory status of the AT profession in 49 states.¹⁵ Following in the footsteps of the United States, the JSPO AT board approved the establishment of a committee for athletic training education system reform in 2017 tasked with updating the current JSPO-approved education system. This is very similar to the time NATA's Board of Directors formed the Education Council in March 1996, which occurred 2 decades after the establishment of the certification exam in 1970. If athletic training history repeats itself in Japan, Japanese athletic training may enter the next growing stage, which is the establishment of the mutual recognition agreement. However, in order to apply for the mutual recognition agreement, JSPO has to complete various steps, such as conducting practice analysis for the assessment of practice equivalency and setting the minimum educational requirement at the level of a bachelor's degree. In each country, athletic training professionals and their local accreditation and credentialing agencies need to carefully consider the role of ATs in the respective health care and social models of their country. As mentioned in an editorial by Ferrara, the goals of athletic training professionals are universal: attaining the best health care for their patients.¹⁶

Limitations

Although this study was the first study to our knowledge that identified differences between BOC-ATs and JSPO-ATs, there are limitations. First, current data were collected via an openly accessible Web-based survey that was distributed to JSPO and JATO members, which may have led to a skewed representation of ATs in Japan. For example, age groups represented in our sample for BOC-ATs were limited, with no respondents aged 20–24. Second, we acknowledge that a cohort of Japanese ATs who participated in the current study were both JSPO-ATs and BOC-ATs (n = 37); for the purpose of our analysis, we merged these individuals within the BOC-AT group because the list of competencies and amount of clinical observation hours required to become certified as a BOC-AT is much more extensive than for a JSPO-AT, and these ATs are likely to be influenced by US athletic training education. Third, while all JSPO-ATs are registered members of the JSPO, Japanese BOC-ATs are not mandated to become JATO members. Therefore, future studies should aim to further increase sample size in order to improve the generalizability of our findings. Lastly, although we based our survey on questions previously validated in the GPA,^8,9 we were not able to conduct a validation check for the survey we used in the current study. However, we believe that the chance of inaccurately collecting data pertaining to the participant's own job description is very low.