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. The US Census Bureau has projected the percentage of minorities to increase from 30.6% in 2000 to 34.9% in 2010, eventually leveling out over the next 40 years.1 Based on the National Collegiate Athletic Association's Race and Ethnicity Self-Study, the number of male and female minority athletes in Division I increased from 31.5% in 1999–2000 to almost 34% in 2004–2005.2 However, these numbers do not represent the certified membership of the National Athletic Training Association (NATA), which comprises 86.6% white, 2% black, 3% Hispanic, 3% Asian, 1% other, 0.4% American Indian/Alaskan native, and 4% unspecified members.3 Some certified athletic trainers (ATs) might not be aware of cultural differences between themselves and their athletes and patients, unknowingly creating a setting that is uncomfortable for diverse individuals. These clinicians must possess the ability to use resources to make accurate diagnoses for patients from a culture other than their own. The profession should include more targeted cultural competence training in education and professional development to consider cultural issues when delivering care.

Diversity means accepting people who are different from oneself or being more inclusive and accepting of students, athletes, or colleagues regardless of color, national origin, race, religion, sex, or sexual orientation.4 To be culturally competent means to understand and integrate differences and incorporate them into daily care and to work effectively in cross-cultural situations, which is also known as transcultural health.5 The demand for culturally competent health care arises from the need to provide medical services to all segments of the population, especially with language and cultural barriers of non–English-speaking immigrants and racial and economic barriers faced by people of color.6 Due to past and current disparities and inequities, the profession of athletic training should develop a culturally competent system built on awareness of the integration of health beliefs and behaviors, disease and injury prevalence and incidence, and treatment outcomes for diverse patient populations to prevent these disparities among ATs' athletes and patients. However, before developing a culturally competent system, the level of cultural competence must be assessed to analyze the areas in which ATs are proficient.

There are 365 entry-level athletic training education programs (ATEPs) accredited by the Commission on Accreditation of Athletic Training Education (CAATE)7 and more than 30 000 ATs nationwide.8 As the profession of athletic training grows, our knowledge of culturally competent health care delivery must grow. Because cultural competence education and care is included in the 4th edition of the NATA's Athletic Training Educational Competencies,9 the assumption that CAATE-accredited ATEPs have included cultural competence education and diversity training within their curricula can be made. However, cultural competence content might be in the form of a stand-alone college course, discussion within a college course, or other form of training. The training might or might not be specific to athletic training because each ATEP decides the appropriate way to deliver the content.

We found only 3 articles on cultural diversity or culturally competent care in which the researchers focused on ATs. One of the first articles on athletic training diversity was an editorial by Perrin4 in which he described the need for promoting diversity in athletic training. In 2003, Geisler10 assessed the benefits of including multicultural education, awareness, and training in ATEPs. Grant-Ford11 wrote an editorial on working toward cultural competence in athletic training, outlining key points essential to the progression toward culturally competent care.

Due to the increasing diversity among the athletes and patients of ATs, the evaluation of culturally competent service is imperative to the profession of athletic training. Therefore, the purpose of our study was to assess the level of cultural competence in health care delivery from ATs. We examined the relationship between cultural competence and sex, race/ethnicity, years of athletic training experience, and NATA district. We hypothesized that ATs would be culturally competent and that no differences would exist in the level of cultural competence between male and female ATs and among NATA districts. We also hypothesized that ATs of color would experience higher levels of cultural competence than white/Caucasian ATs. Finally, we hypothesized that the level of cultural competence would not be different between newly certified (0–5 years) and experienced (>5 years) ATs.

METHODS

RESULTS

Demographic Information

A total of 3102 participants completed the survey, for a response rate of 22.86% (Tables 1 and 2). Because they provided incomplete data, 159 ATs were excluded from the study. The average age of participants was 35.3 ± 9.41 years. They represented various races/ethnicities, various years of experience (11.2 ± 9.87 years), and all NATA districts (Table 1). Almost two-thirds of the participants (1816/2927 [62.0%]) had earned a master's degree, one-third (975/2927 [33.3%]) had earned a bachelor's degree, and few (138/2927 [4.7%]) had earned a doctorate. In addition, almost two-thirds (1829/2918 [62.7%]) of the participants had graduated from a CAATE-accredited program compared with a little more than one-third (1089/2918 [37.3%]) who followed the former internship route to certification. The most common employment position held by participants was college/university (1072/2928 [36.6%]), followed by secondary school only (681/2928 [23.3%]), clinic/secondary school (523/2928 [17.9%]), other (468/2928 [16%]), and clinic only (182/2928 [6.2%]).

Table 1 Demographics of Certified Athletic Trainers by National Athletic Trainers' Association District, Race/Ethnicity, and Sex^a

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Table 2 Demographics by Racial/Ethnic Group Treated by Certified Athletic Trainers

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More than half (1576/2927 [53.8%]) of the participants had previous diversity training. Participants gained their diversity training in an employer-sponsored program (988/1683 [58.7%]), college course (503/1683 [29.9%]), professional conference or seminar (404/1683 [24.0%]), separate college course for credit (330/1683 [19.6%]), continuing education offering (145/1683 [8.6%]), other diversity training types (121/1683 [7.2%]), and online education (116/1683 [6.9%]). Those who selected “other diversity training types” listed military diversity training, teaching experience, and living/traveling abroad as the most common methods. When asked if their diversity training was specific to athletic training, most (1712/1908 [89.7%]) participants stated the training was not specific.

Cultural Competence Assessment

Results revealed that ATs self-reported a mean of 4.52 ± 0.63 out of 5.0 (90.4%) for overall CCA. After completing the CCA, participants scored an overall mean of 4.80 ± 1.51 out of 7.0 (68.5%), including a mean of 5.65 ± 0.526 on the CAS (80.7%) and 3.95 ± 1.51 on the CCB (56.4%). Therefore, ATs self-reported a high level of cultural competence, but results indicated that ATs operated at a lower level of cultural competence. Results also indicated that ATs' cultural behaviors did not mirror their cultural awareness and sensitivity.

A univariate analysis of variance revealed a difference between sexes (F_1,2929  =  18.63, P < .001) (Table 3). Specifically, female ATs (4.90 ± 2.0) were more culturally competent than male ATs (4.64 ± 1.03). We also found a difference among races/ethnicities (F_1,2925  =  6.76, P  =  .01) (Table 4), with the highest cultural competence scores reported for multiracial/other and black/African American groups. The least culturally competent group was American Indian/Alaskan native; the white/Caucasian group scored midrange. We found no differences between years of experience of ATs (F_1,2932  =  2.34, P  =  .11) (Table 5) or among the 10 national and international NATA districts (F_1,2895  =  1.09, P  =  .36) (Table 6).

Table 3 Total Cultural Competence Assessment Scores and 95% Confidence Intervals of Certified Athletic Trainers by Sex^a

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Table 4 Total Cultural Competence Assessment Scores and 95% Confidence Intervals of Certified Athletic Trainers by Race/Ethnicity

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Table 5 Total Cultural Competence Assessment Scores of Certified Athletic Trainers by Years of Experience

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Table 6 Total Cultural Competence Assessment Scores of Certified Athletic Trainers by National Athletic Trainers' Association District

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DISCUSSION

No previous empirical research has been conducted to assess the interactions of ATs with racially and ethnically diverse athletes and patients. With the exception of a few editorials and limited research studies, the issue is rarely discussed within the profession of athletic training. Furthermore, baseline levels of cultural competence have not been reported among ATs. Our findings revealed ATs self-reported a high level of cultural competence, whereas the CCA results showed ATs were less competent within the delivery of health care services. This discrepancy might be related to ATs being more aware of cultural issues as measured on the CAS, but behaviors do not necessarily reflect the awareness and sensitivity as measured on the CCB. More than half (53.8%) of the participants had been involved in some form of diversity training; however, only 10.3% had diversity training specific to athletic training. Our finding that ATs with diversity training scored higher on the CCA than ATs without training suggests that diversity education helps increase cultural competence.17

Female ATs scored higher on cultural competence levels than male ATs. One explanation is that more women than men might have been exposed to diversity training. Another explanation can be found in a study by Barak et al.19 These investigators assessed views on diversity and found that white/Caucasian men perceived the organizations for which they worked as more fair and inclusive than white/Caucasian women and racial/ethnic minority men and women.19 White/Caucasian women and racial/ethnic minority men and women also saw more value in and felt more comfortable with issues of diversity than did white/Caucasian men.19 The adversity that women and minorities of both sexes had to overcome in the 20th century in seeking global equality might explain this finding.

Our results showed ATs of color were more culturally competent than white/Caucasian ATs. The most culturally competent group was black/African American, followed by multiracial/other, Hispanic/Latino American, and white/Caucasian groups. The ATs identifying with more than 1 race/ethnicity reported they were reared in a multiracial home, which might have provided more exposure to diverse opportunities and education compared with a single-race/ethnicity home. Ethnicity and race are closely associated in the United States; thus, one also can assume that minority groups that might have greater experiences with discrimination or prejudice, such as black/African American and Hispanic/Latino American groups, might have a better understanding of the relevance of cultural issues in athletic training care than their white/Caucasian counterparts. Arab American/Middle Eastern, native Hawaiian/Pacific Islander, Asian, and American Indian/Alaskan native groups reported a lower level of cultural competence. This finding might be influenced by the levels of assimilation of Asians and Hawaiian/Pacific Islander groups into the white Anglo American culture.20

Lower competence scores might also be associated with the types of patients and athletes that certain ATs treat. An AT who treats clients primarily within his or her own ethnic or racial group might have a lower score. Some researchers21 have suggested that patients prefer health care providers within their same racial or ethnic groups, which is a finding that might apply to ATs. Cooper-Patrick et al21 noted that patients in race-concordant relationships with their physicians rated their visits as more participatory than did patients in race-discordant relationships. Therefore, a patient's culture influences perception of care provided, communication, compliance, and injury/illness assessment and management.22

Other health care professions, such as nursing, have used various evaluation tools to assess culturally competent care. Doorenbos et al18 found nurses were culturally competent, scoring 85% on the CCA. Schim et al17 did not assess competence levels but found that previous cultural competence training and level of educational attainment were indicators of higher levels of cultural competence in nursing. Because providers with diversity training score higher on the CCA than those without training, diversity education is needed in the athletic training profession.17

We found no differences in cultural competence levels between newly certified ATs and experienced ATs. One could argue that new ATs might score higher on cultural competence levels because most participants in this group would have graduated within the last 5 years and, therefore, would have participated in a CAATE-accredited program that required cultural competence education. Conversely, some might argue that more experienced ATs would score higher than new ATs due to their experience levels and opportunities for exposure to diverse situations or continuing education workshops. Although Sargent et al23 stated that cultural competence requires preparation through formal education, the performance of experienced ATs who completed internship routes to certification was comparable with that of less experienced ATs who graduated from an accredited program.

We found no differences in competence levels among the 10 NATA districts, including international ATs. Overall, respondents were distributed evenly by sex, race/ethnicity, years of experience, and education throughout the districts, so competence levels did not vary.

Our study had several inherent limitations. First, a comprehensive literature review identified no instruments specific to athletic training to measure cultural competence levels. Therefore, we modified an existing instrument that was developed to measure cultural competence among health care providers working in a variety of settings.18 Due to the generic nature of the CCA's original version, some of the questions might not have been easily applicable to ATs. Another limitation was a relatively low response rate of 22.86%, although a large number of ATs responded to the survey (3102). In addition, due to NATA membership rights, only 13 568 ATs of 26 234 NATA certified-student, certified-international, and certified-regular members received the inventory. The remaining ATs elected not to receive the survey via e-mail. Investigation of the cultural competence levels of the remaining NATA members and non-NATA members would provide more detailed results.

Our research supported the hypothesis that ATs are culturally competent. However, actual cultural competence scores were lower than self-reported cultural competence scores. This baseline data can raise awareness among ATs that the profession is not as culturally competent as self-reported. This discrepancy will enable ATs to be cognizant of opportunities to obtain further education on diversity issues. In addition, cultural competence is considered a continuum: part of a developmental process and not a goal that is attained and concluded.24 Because baseline data have been collected regarding cultural competence levels, future researchers can focus on the most appropriate method of initial and continuing education for ATs on cultural issues among their athletes and patients. Maurer-Starks25 stated that ATEPs must identify how they will prepare young professionals to provide health care services to diverse populations, which includes individuals of different races, ethnicities, religious affiliations, socioeconomic statuses, and sexual orientations.

Suggestions about how to increase the knowledge of ATs on issues of diversity lead back to the foundational education of ATs and require educators to personally evaluate their respective knowledge bases, experiences, comfort levels, resources, and educational philosophies, improving self-awareness and challenging themselves to identify with personal history, race, ethnicity, and culture.10 Only then can ATs and athletic training students alike gradually become more comfortable with cross-cultural communication and assessments of race and culture. Athletic training educators must increase awareness so students will be better prepared to work with the diverse populations they will encounter as health care professionals.

The information from our study provides a baseline for the level of cultural competence among ATs in their delivery of health care services. Educators can use these findings to develop educational tools that assist professionals in gaining knowledge about working with diverse individuals. Employers can develop profession-specific diversity training modules to enhance cultural awareness among staff. Athletes and patients can be made aware that ATs consider needs that might be culturally determined while providing care. Minimally, these data will raise awareness among ATs, reminding the profession that cultural aspects of care must be considered when treating patients. Optimal outcomes are achieved when health care practitioners possess more knowledge and respond with sensitivity to cultural issues.11 Embracing the differences within and around various cultures and adapting treatment to accommodate every athlete's or patient's needs is a far more equitable goal than simply treating everyone the same. Certified ATs have the unique opportunity to work with a largely diverse population, so they must recognize their responsibility to take advantage of and grow from these experiences to continually provide the best standard of care. Only through applying culturally competent care can ATs provide an optimal healing environment that ultimately will lead to greater patient outcomes and a more holistic level of athletic medicine.