Athletic Trainers' Knowledge and Practice Application of Public Health Topics

Study Design

To assess ATs' knowledge and practice behaviors related to public health topics, we designed a cross-sectional study using a Web-based survey (Qualtrics, Inc, Provo, UT). Indiana State University Institutional Review Board deemed this study exempt.

Public Health Assessment Tool Development

No current measurements of knowledge or practice behaviors related to public health are available in the literature, and as such, the authors, with assistance from a Delphi panel, designed the Public Health Assessment Tool (PHAT) to match the purposes of the study. The Delphi panel comprised a group of experts with background in epidemiology, public health, sports medicine, and athletic training. The Delphi technique is a method of structuring the collective judgments of a group of experts, conducted through a series of sequential questionnaires, each containing summarized information from earlier responses.^18,19 Ten experts (7 ATs, 1 sports medicine physician, and 2 public health educators/researchers) with an average of 17 years of experience (range = 7–31 years of experience) in their respective professions served on the panel.

The panel of experts completed a multiphase process, called rounds, of online review and questionnaires to gather their thoughts and opinions on the content for the instrument. After being posed with the research question and specific aims for the study, the initial round asked the Delphi panel to rank a list of 30 public health topics in order of importance that they believed an AT would need to have the knowledge in related to public health. The initial list of 30 public health topics was developed from the Healthy People 2020 topic areas and relevant athletic training literature.^20–22 The Delphi panel provided panelists a rationale to explain why they believed the ones they ranked were the most important. Additionally, Delphi panelists had the option to provide any additional topics that were omitted from the list. From the responses, the authors were able to identify consensus related to 15 topics, which were transformed into 23 knowledge assessment questions and 18 practice-behavior items. In the second round, the Delphi panelists were e-mailed a copy of the proposed tool, including demographic items. The members were asked to indicate whether each item was adequate as written, should be included in the instrument but must be edited, or should be removed from the instrument.

The primary investigator compiled responses and revised the instrument with 3 knowledge assessment questions removed based on feedback. The PHAT was then transferred into the Web-based platform that would be used for the final study deployment. The Delphi panelists were provided a link containing the PHAT in its entirety to preview the informed consent, participant directions, and instrument flow. Next, the members were provided a questionnaire via a Web-based survey to evaluate the instrument in 3 areas: how the question was worded, how the answer choices were worded, and the appropriateness of the question in the final instrument. Each of the 3 measures were scored on a 5-point Likert scale (inappropriate = 1, appropriate = 5) with the goal to achieve consensus in each of the 3 measures by scoring an average of 70% (3.5 out of 5 on the Likert scale) or higher from the compiled Delphi panelists' responses. Each of the 20 knowledge assessment questions included an open-ended response box for the Delphi panelist to provide suggestions for revisions. The data from round 3 of the Delphi technique identified consensus at or higher than 70% for 16 of the 20 questions in all 3 variables of interest. One question was omitted from the PHAT based on the feedback, and 3 questions required another round of analysis related to the wording of questions or answers. For items that did not meet consensus during round 3, the authors modified the item and created a new questionnaire with the specific knowledge assessment questions and analysis item. Content consensus was reached after the fourth round of the Delphi technique signifying content validity.

After content consensus from the Delphi panel, the authors used a pilot study to evaluate instrument flow, navigation, and internal consistency for the PHAT. For the pilot study, 200 currently credentialed ATs in good standing from the National Athletic Trainers' Association (NATA) membership database were recruited with a 1-time e-mail with no reminders; the study remained open for 1 week. Six participants completed the pilot study in its entirety. The data were not used for the final statistical analysis and all participants recruited for the pilot study were removed from the potential recruitment list for the final study data collection. The outcomes of the pilot study determined that the 19-question knowledge assessment resulted in strong internal consistency (Cronbach α = 0.630). An “item-if” analysis was used to determine if a change in internal consistency occurred if any of the 19 items were removed. This assessment did not change the internal consistency of the PHAT. Overall, 7 of the 19 questions had a 100% correct response rate from the pilot participants, 1 question had a 0% correct response rate from pilot participants, and no major changes were made to the PHAT before final study distribution.

Instrument

The final instrument for this study included a demographic section (5 items), a pre-PHAT perceived-knowledge assessment (5 items), a practice-behavior matrix (Table 1, 18 items), the PHAT developed by the authors and Delphi panelists (19 items), and a post-PHAT perceived-knowledge assessment adapted from the literature (5 items).

Table 1 Self-Reported Frequency of Public Health Topic Practice Behavior, No. (%)^a

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The demographic section included items related to the age, years of credentialed athletic training experience, clinical practice setting using the NATA membership database categories, highest level of education, and gender of the participant. The pre- and post-PHAT perceived-knowledge assessment was adapted from the literature.²³ The PHAT contained a 19-item, multiple-choice actual-knowledge assessment that included both knowledge-retrieval (returning information) and knowledge-use (making care decisions) items. Finally, the practice-behavior matrix asked participants to identify how frequently, if at all, they implemented each of the public health topics into their clinical practice. The anchors for the matrix included never, daily, weekly, monthly, every 6 months, annually, unsure how to do the task, and task was unnecessary for their job.

Procedures

After approval from the Institutional Review Board and the pilot study, recruitment e-mails were sent at variable times of day to 6466 ATs who were members of the NATA on February 5, 2019, with 5 reminder e-mails sent weekly; the final reminder was sent on March 4, 2019, and the study closed on March 11, 2019. After electronically indicating informed consent, the participant began the instrument.

Participants

Of the initial 6466 recruitment e-mails sent, 750 ATs opened the survey link (access rate = 11.6%). Of the 750 who opened the link, 666 ATs responded to a portion of the instrument (response rate = 10.3% of total recruited population, 88.8% of accessed population) with 500 completed responses collected, meaning that participants completed the final question but could skip questions as they wished according to best practices in survey research (completion rate = 75.1%). During the data extraction process of the 500 completed responses, 12 responses were removed as ineligible (6 did not agree to participate or did not identify as a currently credentialed AT) and 1 response was removed as the participant had finished the instrument but did not answer any of the perceived-knowledge assessment or the PHAT items. A total of 487 participants (35.8 ± 11.1 years old, 12.8 ± 10.6 years of credentialed experience) were included in the analysis. Table 2 shows the background of the participants, which also supports the representativeness of the study itself as well as the profession of athletic training.

Table 2 Demographics of Participants

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Statistical Analysis

Data were collected and transferred from the Web-based survey platform into custom spreadsheet software (Microsoft Excel 2016; Microsoft Corp, Redmond, WA) for data cleaning. Next, all data were transferred and analyzed using commercially available statistical analysis software (SPSS version 25.0; IBM Inc, Armonk, NY). Measures of central tendency (mean, mode, interquartile ranges, and standard deviations) were calculated for all variables of interest. For the perceived-knowledge assessment, the 5 items included both positive (n = 2) and negative (n = 3) question stems that were reverse score corrected to avoid response bias. The perceived-knowledge questionnaire was calculated as a mean per participant before and after the PHAT. Data were coded for the PHAT with each correct answer counting as 1 and each incorrect or omitted answer as 0. A pairwise comparison was used to evaluate the change in perceived knowledge after the PHAT. A Pearson correlation was used to identify a knowledge gap. The α level was set at P = .05 a priori.

Practice Behaviors

A majority of participants stated they practiced several skills daily, including handwashing (n = 412, 84.6%) and encouraging physical activity/exercise (n = 393, 80.7%). The public health topic that was most frequently practiced either monthly (n = 104, 21.4%), every 6 months (n = 84, 17.2%), or annually (n = 193, 37.6%) was related to creating, implementing, and reviewing policies. The topic that had the highest frequency for never being practiced was promoting community health efforts in surrounding neighborhoods (n = 140, 28.7%). On the same note, the 3 topics the participants were most frequently unsure how to implement included evaluating the determinants of wellness reflective to a patient (n = 49, 10.1%), assessing health-related quality of life (n = 26, 5.3%), and assessing environmental health factors (n = 25, 5.1%). Table 1 provides the full breakdown of public health topics with frequency of reported behaviors from the participants.

Knowledge Assessment: Perceived, Actual, Correlation

On the perceived-knowledge assessment, participants ranked themselves at a mean of 4.13 ± 1.00 before the PHAT and at a mean of 3.95 ± 1.00 after the PHAT. A significant difference was identified when comparing the means of the perceived-knowledge assessment before (mean = 4.13 ± 1.00) and after (mean = 3.95 ± 1.00) the PHAT, yet it was not clinically meaningful (95% confidence interval = 0.12, 0.24; P > .001). From the sample, the interquartile ranges for the items “I know pretty much everything about public health” (25th percentile = 2) and “I do not feel very knowledgeable about public health” (25th percentile = 3) decreased meaning that the participants struggled to identify their perceived knowledge. Upon further evaluation, the participants in the 75th percentile had a reduction in their percentile mean value by 1 data point in those 2 areas meaning that they expressed a heightened self-awareness after completing the PHAT. Table 3 provides a statistical analysis of the 5 perceived-knowledge assessment items at both time points in the study.

Table 3 Perceived-Knowledge Assessment

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On the PHAT (Table 4), the participants scored a 12.14 ± 2.21 out of 19 (63.89%) with a range of scores between 3 (15.79%) and 18 (94.74%). At face value, the 3 most commonly missed questions on the PHAT directly related to the 3 topics in which the participants were most frequently unsure of how to implement on the practice-behavior matrix. This included evaluating the determinants of wellness reflective to a patient (PHAT question 6, 29.6% correct), assessing environmental health factors (PHAT question 18, 25.7% correct), and assessing health-related quality of life (PHAT question 14, 3.5% correct). When exploring the relationship between perceived and actual knowledge, we identified a knowledge gap based upon a poor relationship (r = 0.38, P = .402). Finally, we did not identify significant differences between groups of participants with 1 to 5, 6 to 10, 11 to 15, 16 to 20, 21 to 25, and more than 25 years of credentialed experience with regard to actual-knowledge score (F_5,485 = 2.199, P = .05), whereby the differences between groups was nominal (range = 11.78–12.82 points).

Table 4 Public Health Assessment Tool

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Public Health: Current Realities and Future Direction

The Institute for Health Improvement developed the Triple Aim framework, which describes 3 overall goals for health systems to strive for in order to optimize the systems performance.⁵⁶ The Triple Aim for population health includes a 3-pronged approach: improvement of the individual patient experience, improved health of populations, and lowering the costs associated with health care.⁵⁶ These 3 individual goals of the Triple Aim are interconnected, meaning that attempts to achieve one goal could impact the others. For instance, if providers want to improve individual patient health or experience, this potentially could increase health care costs. Therefore, it is imperative that ATs have a better understanding of not only individual-level and population-level public health concepts, but also how these initiatives impact the cost of care and influence one another. From the population health dimension, measures of health/functional status,^57,58 assessing risk,^59,60 understanding the incidence and prevalence of diseases,^61,62 and appreciating the years of potential life lost^63,64 are all relevant standards for ATs to be competent in as they deliver patient care.

The public health realm has 3 domains and 10 essential services related to public health.⁶⁵ The 3 domains are health services, health protection, and health improvement.⁶⁵ In health services, the essential services include assuring a competent health services workforce, evaluating health services, linking people to needed health services, and developing policies and plans.⁶⁵ The health protection domain includes the essential services of enforcing laws and regulations, protecting the environment and workplace, and diagnosing and investigating health problems.⁶⁵ Finally, the health improvement domain includes informing, educating, and empowering the public; monitoring health status of the population; and mobilizing community action.⁶⁵ The data gathered in this study indicate that ATs may need continuing education directed at these 3 domains, specifically health protection and health improvement.

As the intersection of athletic training and public health occurs, ATs who are working in both the clinical and education sectors must be cognizant of the Triple Aim and the public health essential services.⁵⁶ The current realities include a movement for population health with activities designed and directed to improving the health of the patient.⁵⁶ In athletic training, we have continually focused on implementing the measures of the population health dimension through a singular lens, without respect to our colleagues' experiences throughout the country. Particularly in the area of sport-related concussion, we have placed an emphasis on sharing injury prevention methods such as the Heads Up Football program with stakeholders at the interpersonal and community levels of the socioecological model of intervention.^66,67 As we continue to progress, interprofessional educational opportunities centered on public health may be an advantageous technique that brings learners from several disciplines together for a common goal to achieve the Triple Aim and maximize potential team-based care.^68,69 Moreover, ATs should consider that teamwork does not always mean working alongside other members of the health care community. The socioecological model of public health stresses the importance of how interactions with different levels of influence can determine the health of the individual.⁶⁷ The framework emphasizes the role of intraprofessional practice, or the collaboration of ATs to gather, analyze, and communicate patient outcomes.⁷⁰ Although the practice is uncommon throughout daily clinical practice, the dissemination of data is essential to epidemiology and injury surveillance.³⁵ As a profession, we must educate future ATs and encourage practicing clinicians about the “how” and “why” of intraprofessional collaboration through the lens of injury surveillance.

Educating the Next Health Care Leader

One of the findings of this study demonstrated that ATs scored lower and felt less confident in their ability to evaluate social determinants of health, environmental factors, and health-related quality of life of their patients. If ATs are unable to appropriately determine factors that will influence their patients' health and overall health-related quality of life, they will not be able to inform, educate, or empower patients, nor will ATs be able to guide or connect patients to the appropriate needed health services.⁷¹ Further, the inability of ATs to assess environmental conditions makes them unable to enforce laws and regulations in order to protect the environment and workplace for their patients.⁷² Therefore, athletic training programs should consider integrating curriculum related to these concepts, specifically on how learners can engage with individual and population-level public health initiatives.

In professional education, we suggest that athletic training program administrators use a spiral curriculum method when addressing public health.⁷³ Although the requirement for foundational knowledge in public health and epidemiology is now listed in the CAATE standards, a program can be compliant with this standard by simply requiring it as a prerequisite course during the preprofessional phase. However, there is a strong likelihood that an introductory public health course will not specifically outline the intersection of public health and athletic training, thus leaving the student without a connection between the 2 fields. We suggest that public health topics be integrated throughout all aspects of the curriculum, rather than a singular class or experience, reinforcing previous learning outcomes while increasing in complexity.⁷³ During the spiral curriculum, we recommend that educators seek to develop students' appreciation for population health while allowing them to practice individual-level public health in order for the students to achieve competence by exploring similar concepts in multifaceted situations.⁷³

For the duration of the curriculum, educators must also consider instructional strategies and educational techniques relative to public health topics. It is most likely that real-time patient encounters and meaningful population health initiatives would emphasize the importance of public health during clinical practice. Previous research⁷⁴ has cited that practical experience related to health care delivery in community-based models provides a valuable opportunity to achieve practical application outside of the classroom. In addition, the use of simulation may serve as a supplement to clinical education with scenarios designed around social justice topics. For example, positive student learning outcomes have been noted with simulations for low socioeconomic status/poverty⁷⁵ and integrating the social determinants of health.⁷⁶

The need to link people with health needs to community resources is the foundation of social determinants of health. The CAATE 2020 Standards for Accreditation of Professional Athletic Training Programs¹² list patient-centered care as a core competency. Under this core competency, standards 56, 57, and 60 highlight the need to advocate for population-based health needs, identify health literacy and social determinants concerns, and use the disablement model for patient care.¹² These standards require the athletic training student to appreciate the role of whole-person health care. Moreover, a professional athletic training student should have opportunities to read policy from the Centers of Disease Control and Prevention Foundation and the World Health Organization as a means to be exposed to the global impact of health and wellness. Finally, educators should consider instructional strategies that allow the athletic training student to inform, educate, and empower the public with regards to their health needs. Outside of didactic education, clinical preceptors must embody and deploy public health behaviors by enforcing laws and regulations, educating the community, and providing opportunities for student growth in public health. Although preceptorship status was not a criterion of the study, we did identify that practicing clinicians, who are all qualified to serve as preceptors, lacked the practice behaviors and knowledge of key public health topics. It is vital that this knowledge and practice gap be narrowed during clinical practice.

In postprofessional athletic training programs, educators should consider incorporating several of the concepts we described in the professional education section with the emphasis of expanding the depth and breadth of students' base knowledge. Postprofessional athletic training students must be in an endless loop of integrating policy with practice. For example, the clinician must develop policies and plans with evaluation tactics. The American Association of Colleges of Nursing sets similar standards for the doctor in nursing practice (DNP) degree, requiring that graduates be able to develop and evaluate care delivery on a system level to entire patient panels, not just individual patients.⁷⁷ Further, DNP graduates are expected to use health policy to develop practice-level and system-level initiatives to improve the quality of care.⁷⁷ There is a need to evaluate their (DNPs and ATs) health care services through quality improvement and point-of-care analyses.⁷⁸ And finally, postprofessional athletic training students should mobilize community action. Throughout this process, the educator can maximize the clinical education opportunities of the practicing clinician. There should be emphasis placed upon exploring and challenging the status quo of health care with regards to community service learning opportunities⁷⁹ by intermingling the daily patient panel with community health tactics to implore behavioral change.

Finally, with regards to residency and fellowship programs in athletic training, we must be cognizant of the specialty area with a direct link to public health. The CAATE has identified 8 specialty competency areas of focus for athletic training residency programs, with one area being prevention and wellness. As of 2019, there are no residency programs accredited in this focused area of practice. The authors recommend that educators and clinicians wishing to create a prevention and wellness residency program ensure that the AT be able to develop advanced practice behaviors consistent with the focused area of practice. In medicine, the preventative medicine specialty area is assessed using the public health and general preventive medicine milestones that are fully described in Table 5.⁸⁰ Through these milestones, we believe an AT with specialty preparation in this area of focus should be able to diagnose and evaluate health problems, mobilize community action, monitor the health of the population, and empower the public.

Table 5 The Preventive Medicine Milestone Project

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Becoming an Agent of Change Versus a Passive Observer

Educational theory has supported the concept that the more involved a learner is, the greater the amount of memory and replication that will be able to occur. Athletic training programs should be preparing students to engage in and practice these public health topics as change agents rather than as passive observers. A change agent has been defined as one who takes on the role for initiation and management of change, whereas a passive observer does not engage with the process and initiation of change.⁸¹ For example, as ATs record and document as passive observers, they are completing a key aspect of patient care, yet the data remain only in the electronic medical record.^82,83 To become a true change agent, the AT should consider downloading and analyzing the patient's medical record to create specific prevention and wellness plans based on risk and previous injury. Finally, ATs should consider compiling injury data from their clinical site to initiate prevention policies based on their findings.^84,85 The final step is how an AT accomplishes both population-level public health practice and being a change agent in the profession.

The modeling of these behaviors, which is rooted in social learning theory,¹³ to other ATs and students can socialize those around them to the importance of implementing not only individual-level but population-level public health initiatives. It is also key that the athletic training student be not only observing, but also actively engaged in authentic experiences that are facilitated by preceptors, which is a trademark of experiential learning.⁸⁶ As such, athletic training programs should consider preparing students to take on the role of becoming change agents by practicing public health topics at both the individual and population levels. Specifically, ATs can accomplish this through modeling behaviors.

Limitations and Future Considerations

The limitations of this study are respective to the participants we studied. For the purpose of the study, we examined practicing clinicians. The new standards will be deployed for upcoming athletic training students, yet are not required for the already practicing clinician. We believe the knowledge and practice behaviors for the public health topics could be based on educational background, previous clinical practice experiences, media exposure, and other contextual factors. While the call to action in previous literature was to explore ATs' knowledge and integration of population health, we sought to study the knowledge and integration of individual-level public health topics. The goal now is to take the individual-level data collected from this study accompanied by the curricular recommendations for athletic training programs in the discussion on how we, as a profession, can leverage our foundational knowledge of public health into a population health model. As such, future research should explore the successes and barriers to population health implementation for the practicing clinician.