Compliance With the National Athletic Trainers' Association Inter-Association Task Force Preseason Heat-Acclimatization Guidelines in High School Football

Study Sample and Recruitment

The population of interest was NATA-affiliated ATs working with US HS football programs during the 2017 season. To be eligible for inclusion in the study, ATs had to (1) have a valid e-mail address, (2) be NATA affiliated, (3) have opted in to take surveys on the NATA membership list, and (4) be either directly employed by a school district or working in the HS football setting via outreach for a clinic, hospital, or physician practice.

An invitation to participate was sent to all ATs on the NATA membership list who met the first 3 criteria (N = 7278). Nonrespondents received e-mail reminders on a biweekly basis during the 4-month data-collection period (December 2017 to March 2018). The membership list included ATs working in HSs that did not sponsor football, but we could not discern which ATs worked in such settings. Thus, responding ATs were asked whether they worked with an HS football program during the 2017 season; those responding that they did not were notified that they did not meet the criteria to participate (n = 92). Of the remaining 7186, 1214 began the survey, and 1023 completed it. This led to an estimated 14.2% response rate, although this rate may be underestimated by additional ATs who did not work with HS football but did not notify us. The sampling strategy was unable to account for whether responding ATs from the same HSs responded to the survey.

Survey Instrument

The survey used was replicated from the previous study,¹³ whose investigators reviewed the NATA-IATF guidelines⁶ and identified 17 specific items to use as key metrics. These 17 guidelines were grouped into 6 major categories (Table 1). We retained the guidelines and categories to allow for comparability with the previous study.¹³

Participating ATs provided information on whether the HS football programs with which they worked complied with the NATA-IATF guidelines during the 2017 preseason. The preseason was defined as the period, usually 2–3 weeks before the first game of the regular football season, characterized by athletes participating in football-specific training, in which equipment is phased in and football-specific training and skills are conducted. This definition excluded summer conditioning that occurred before football-specific training. We also emphasized that the focus of this compliance was on the HS football programs and not the ATs; this was done intentionally to ensure that participating ATs were comfortable providing answers that might indicate noncompliance.

The survey never explicitly mentioned the implementation of the 17 specific NATA-IATF guidelines. This was done to minimize the potential for reporting bias. The survey also collected ATs' demographic information and experience and school-related characteristics including state, enrollment size, and number of student-athletes at their school(s) during the 2017–2018 school year. Last, ATs provided data on their HS football program's 2017 preseason training, including the size of the preseason squad and the schedule of practice sessions and rest breaks.

The previous survey¹³ had been pilot tested with a convenience sample of 11 ATs from 2 universities who provided care to HS athletes in order to ensure that the content was clear, concise, and error free. Similarly, we pilot tested the current survey with a convenience sample of 5 ATs who provided care to HS athletes. We explained the study purpose to the ATs pilot testing the survey, emphasizing our intent to ensure comparability between our findings and the previous investigation. The ATs' recommended changes, which focused on aiding participant comprehension, were applied to the survey.

Statistical Analysis

We were interested in how compliance differed between (1) the 2017 and 2011 HS football preseasons and (2) the HS football programs in states whose athletic association–mandated guidelines for football preseason heat-acclimatization met (with-mandate group) or did not meet (without-mandate group) the criteria set forth by the NATA-IATF guidelines. We calculated the number of guidelines with which each respondent indicated school compliance. From this, we computed the percentage of HS football programs whose ATs reported compliance with each of the 17 NATA-IATF guidelines and full compliance (ie, all 17 guidelines; Table 1). We also computed the percentages reporting compliance with ≥10 guidelines. This cutoff was selected to aid comparability with the previous finding¹³ that 57.9% reported compliance with ≥10 of the guidelines during the 2011 preseason.

To test hypothesis 1, we reexamined data from the original 2011 study.¹³ The 2011 sample consisted of a cross-section of 1142 ATs from all 51 US jurisdictions except Alaska and Rhode Island.¹³ Most were male (51.8%), with an average age of 37.0 ± 10.2 years and more than 10 years of experience (57.9%), and worked in HSs with 2011–2012 school-year student enrollments greater than 1000 (62.6%).¹³ Because of the deidentified nature of the data collected for the studies, we were unable to account for how many ATs participated in both. Prevalence ratios (PRs) compared the prevalence of compliance between the groups. An example of a PR comparing full compliance in 2017 versus 2011 preseason is

A Wilcoxon rank sum test also compared distributions of the number of guidelines with which programs complied in 2017 and 2011.

To test hypothesis 2, we compared results between ATs working in states with mandates, with partial mandates, and without mandates. The 8 states that met the NATA-IATF guidelines during the 2017 HS football season (with mandate), as indicated by Adams et al,¹¹ were Arizona, Connecticut, Iowa, Mississippi, New Jersey, North Carolina, Rhode Island, and Utah. The partial-mandate group consisted of those from states whose guidelines included (1) meeting at least 1 of the NATA-IATF guidelines or (2) a comprehensive plan that considered all of the NATA-IATF guidelines but lacked best-practice wording (eg, using “should” over “must”). This consisted of 24 states, as identified by Adams et al.¹¹ All remaining states were included in the without-mandate category. Prevalence ratios with 95% confidence intervals (CIs) compared compliance prevalences among the 3 groups. A Kruskal-Wallis test was used to compare distributions.

All PRs whose 95% CIs excluded 1.00 were considered statistically significant. We were concerned that the large sample size (N = 1023) might result in small effect estimates (ie, PR close to the null) being statistically significant. Thus, our findings focused on those statistically significant PRs that (1) indicated moderate associations (PR ≥1.40 or ≤0.71)¹⁵ and (2) yielded differences of ≥15.0 percentage points between the groups; t statistics, F ratios, and Tukey post hoc comparisons with P values <.05 were considered statistically significant.

Characteristics of the ATs and HSs

Characteristics of the ATs and their HSs are presented in Table 2. All US jurisdictions except Alaska were represented, with the largest proportions from Texas (10.3%), Pennsylvania (7.4%), California (6.7%), New Jersey (5.1%), and Ohio (5.1%). Overall, 15.6% of respondents worked in states with mandated heat-acclimatization guidelines. Of the 84.6% in states without such mandates, 501 (49.0% of the total sample) worked in states with partial mandates.

Table 2 Athletic Trainer (AT) and High School (HS) Characteristics (N = 1023), 2017 Football Preseason

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Overall Compliance With the NATA-IATF Preseason Heat-Acclimatization Guidelines

Overall, ATs reported that their HS football programs complied with an average of 12 ± 3 of the 17 individual NATA-IATF preseason heat-acclimatization guidelines (median = 12; interquartile range [IQR] = 9–14; Figure). However, this distribution was skewed left, with the majority of ATs reporting compliance with ≥10 guidelines (73.9%). Only 3.9% reported full compliance with all 17 guidelines (Table 3).

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Table 3 High School Football Programs Complying With National Athletic Trainers' Association Inter-Association Task Force Preseason Heat-Acclimatization Guidelines During the 2017 Preseason

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The guidelines with the most compliance were “no more than 2 practices per day” (96.6%); “1 day of complete rest after 6 consecutive days of practice” (95.4%); “AT must be on site before, during, and after all practices” (93.1%); and “double-practice days consisted of practices no more than 5 hours in length in total” (91.0%; Table 3). In contrast, the guideline with the least compliance was “a 3-hour recovery period occurred between the practice and walk-through (or vice versa)” (44.7%). A number of additional guidelines also had low levels of compliance, particularly those related to equipment alterations and contact drills.

Comparison of the 2017 and 2011 Preseason Data (Hypothesis 1)

The distributions of the number of guidelines with compliance differed between 2017 (median = 12; IQR, 9–14) and 2011 (median = 10; IQR, 8–13; Wilcoxon rank sum P < .001). The proportions of HSs that were fully compliant were not statistically different (3.9% versus 2.5%, respectively; PR = 1.54; 95% CI = 0.96, 2.46; Table 3). However, the proportion that was compliant with ≥10 guidelines was higher in 2017 than in 2011 (73.9% versus 57.9%, respectively; PR = 1.28; 95% CI = 1.20, 1.36). Certain guidelines had at least moderate associations with differences ≥15.0 percentage points, including “double-practice days did not occur during first 5 days of formal football practices” (70.4% versus 41.2%, respectively; PR = 1.71; 95% CI = 1.58, 1.85); “single-practice days consisted of practice no more than 3 hours in length” (60.2% versus 39.7%, respectively; PR = 1.52; 95% CI = 1.39, 1.66); and “2 practices were separated by a break of at least 3 continuous hours that was in a cool environment” (69.3% versus 48.9%, respectively; PR = 1.42; 95% CI = 1.32, 1.52).

Comparison of States With and Without Mandated Guidelines (Hypothesis 2)

The distributions of the number of guidelines differed among the with-mandate group (median = 14, IQR = 11–15), partial-mandate group (median = 12, IQR = 10–14), and without-mandate group (median = 10, IQR = 8–13; Kruskal-Wallis P < .001). The proportion of respondents reporting their HSs were fully compliant was highest among the with-mandate group (9.4%), followed by the partial-mandate group (4.6%) and the without-mandate group (0.6%; Table 4). All prevalences were statistically different. Similar differences among groups were present when we examined compliance with ≥10 guidelines (with mandate = 85.0%, partial mandate = 80.6%, without mandate = 59.7%). Similarly, for specific guidelines, the with-mandate group had the highest level of compliance with regard to double-practice days, equipment alterations, and when contact drills occurred.

Table 4 High School Football Programs Complying With National Athletic Trainers' Association Inter-Association Task Force Preseason Heat-Acclimatization Guidelines During the 2017 Preseason by Whether Guidelines Were Fully, Partially, or Not Mandated by State's High School Athletics Association Continued on Next Page

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Hypothesis 1: Improvements in Compliance During the 2017 Preseason Versus the 2011 Preseason

The percentage of programs in full compliance was not statistically significantly different between the 2017 and 2011 preseason studies. Nonetheless, the 54% higher prevalence in 2017 versus 2011 is considered a moderate association and may be clinically significant.¹⁵ In addition, the percentage of participants reporting compliance with ≥10 guidelines increased. Why such increases occurred is unknown. Educational efforts, including those within athletic training education and continuing education programs, may have resulted in increased knowledge and subsequent implementation of the NATA-IATF guidelines. Also, ATs in our study as compared with the previous study may have first been exposed to the guidelines in different manners; those in the current study with less experience would likely have seen this information during their education, compared with those from the previous study, who may have had to learn this information on their own or via continuing education. Future investigations may inform as to how the mode of education about these guidelines affects ATs' understanding and implementation. Despite this, the low level of full compliance highlights the need for research to identify the barriers and facilitators that affect implementation of the NATA-IATF guidelines and the safety of football preseason practice settings. In particular, such authors can focus on those specific guidelines that had lower levels of compliance, such as “a 3-hour recovery period occurred between the practice and walk-through (or vice versa)” (44.7%), and those related to equipment alterations and contact drills.

A number of factors may play a role in limiting compliance with certain guidelines. Regarding 3-hour recovery breaks between practices and walk-throughs, coaches may not see the need because they perceive the walk-through as not being strenuous. Also, coaches may shorten the recovery time because it is logistically easier than keeping students on site for extended periods of time or requiring them to show up for football-related activities multiple times per day. Education may be important in emphasizing that the aims of this 3-hour break are to aid recovery from fatigue¹⁸ and fluid deficit¹⁹ and return core body temperature from high to normal levels.^19–21 Other guidelines, such as limiting equipment and the use of contact drills during the first week of practice, may also be facilitated by increased education for HS football coaches and administrators. Because data verifying the reasons for noncompliance are limited, work is warranted to further explore the implementation of the NATA-IATF guidelines. In particular, strategies are needed to overcome barriers related to logistical planning and perceived inconvenience.

Hypothesis 2: State Mandate of NATA-IATF Guidelines and Compliance

Previous researchers¹² found that states whose HS athletic associations mandated NATA-IATF guidelines were more likely to have HS football programs in better compliance than those states without mandates. These results were replicated in our study, with full compliance and compliance with ≥10 guidelines being higher in states with versus without mandates. Thus, mandates created from policy may improve compliance with injury-prevention strategies. Earlier authors²⁰ noted that policy-level strategies may result in more effective changes than behavioral strategies, although prevention in general may benefit from considering individual, interpersonal, and environmental factors. Given that state-level mandates of the NATA-IATF guidelines potentially increased compliance, it may be warranted for state HS athletic associations to mandate NATA-IATF guidelines while ensuring HSs have the appropriate organizational support to properly implement the guidelines. Also, although the analyses showed benefits from partially mandated guidelines, we did not specifically examine which specific types of partial mandates were associated with increased compliance. Still, the large discrepancies seen in states with full mandates compared with states with partial or no mandates further demonstrate that the strongest benefits of mandates occur when they include all recommended best practices.

Limitations

Our study had a 14.2% response rate from HSs with ATs, which may have resulted in a sample that was not generalizable to all HS football programs, particularly with 30% of HSs lacking AT coverage nationwide.²² Our estimate of compliance may be an overestimation, as our sample did not include HSs without ATs. In addition, respondents may have been more knowledgeable about EHI prevention and more likely to ensure proper implementation of the NATA-IATF guidelines. We were unable to account for whether responding ATs from the same HSs responded to the survey or had previously responded to the 2011 survey. Our study may also be limited by the typical biases related to survey research, such as recall and social-desirability bias. However, the ATs were likely to have had good recall of preseason practice sessions because supervision of these sessions is a well-accepted role of ATs.

Although we provided overall comparisons with data gathered from the 2011 preseason,¹³ we were unable to compare those states noted as being compliant in the 2011 and 2017 preseasons, as the methods for classifying states varied between the studies. We opted to use more stringent categorizations of compliance based upon recent research¹¹ that we believe to be more valid than those used in the previous assessment. Also, our outcome measures for assessing compliance with all 17 and ≥10 guidelines were chosen to aid comparability with the earlier research¹³ but may not account for all variability in responses during the comparative analyses. Finally, because we relied on ATs as respondents to describe current practices at their HSs, we were unable to account for the roles of other football program stakeholders, including coaches, administrators, and parents. Given the limitations of the current study, future research is warranted to evaluate other facets of EHI prevention, including the education provided to coaches and players and specific barriers to and facilitators of compliance.