Board of Certification Examination Achievement Gaps as a Barrier to Diversifying the Athletic Training Profession

Health disparities have been linked to a lack of diversity among health care providers. The role of diversity in diminishing health disparities is grounded in the principle that health administrators from ethnic minority groups are more likely to organize health care delivery systems that meet the needs of patients from underrepresented minority groups.¹ Furthermore, providers from ethnic minority groups are more likely to care for patients from underrepresented minority groups, practice clinically in impoverished areas, and provide more effective care to patients of their own ethnicity.^2–4 However, despite continuing efforts to improve the diversity in the health care workforce, individuals from racial or ethnic minority groups continue to be underrepresented in the health professions. For example, 80.8% of physician assistants,⁵ 84.3% of physical therapists,⁶ and 81.5% of athletic trainers (ATs)⁷ self-identified as non-Hispanic White. These demographics fail to reflect the increasing diversity of the US population and perpetuate a crucial demand for qualified individuals from underrepresented ethnic groups to enter the health professions.

Higher education serves as a fundamental pathway to social mobility and economic opportunity in the United States. However, unfortunately, achievement and opportunity gaps are often influenced by disparities in the experiences of students in their K–12 education. Inequities are embedded in the educational laws, policies, and institutions of the United States, which often oppress underrepresented minority students in separate and unequal educational experiences. Individuals from underrepresented minority groups were more likely to attend schools that lacked instructional resources, including adequate funding and resource allocation in addition to skilled teachers and quality curricula.⁸ As a result, a disparity in academic performance occurs between White students and those from underrepresented minority groups. Most pronounced in mathematics and science, these achievement gaps can be displayed through grades, standardized test scores, and other academic success measures.⁹ Subtle inequalities in achievement are present at the start of a child's education and, by the end of fifth grade, are already sufficient to begin separating students who are White and those from underrepresented minority groups.⁹

As students from underrepresented minority groups age and progress through the educational system, psychological distress becomes more prevalent.⁹ Awareness of the achievement gap results in stress and anxiety for highly motivated students who are threatened by the potential for confirming negative stereotypes about academic performance by their racial or ethnic group. These emotions can place higher demands on their mental resources and subsequently impede performance. Furthermore, their attempts to suppress these negative thoughts can overload working memory, leading to performance deficits on cognitively demanding tasks, particularly on tests of learned knowledge.^10,11 Stereotype threat can negatively affect test-taking skills, such as test-wiseness, memory, and time management for students from underrepresented minority groups.⁹ Deficits in these technical skills may lead to underperformance, particularly in health professions education, which requires prerequisite knowledge of mathematics and science. The effects of stereotype threat are potentially devastating for students from underrepresented minority groups who rely on high-stakes standardized examinations to enter the medical and health professions.⁹

Students from underrepresented minority groups in schools of health professions performed markedly worse on credentialing and licensing examinations than their White counterparts. For example, nursing programs with higher percentages of White students were more likely to have higher pass rates on the National Council Licensure Examination for Registered Nurses (NCLEX-RN) than nursing programs with smaller percentages.¹² Investigators of predictors of success in nursing education established that, while 58 students, or 92.1% (n = 63), of White students passed the NCLEX-RN on the first attempt, only 6 African American students, or 60% (n = 10), did the same.¹² Underperformance on credentialing and licensure examinations by those from racial and ethnic minority groups appears to hold true even when students have been admitted into graduate programs based on their grade point average, Graduate Record Examination scores, or both. Students from underrepresented minority groups accounted for nearly half of all medical students who initially failed Step 1 of the United States Medical Licensing Examination.¹³ Furthermore, when controlling for other factors, the odds of failing the National Physical Therapy Examination were more than 200% higher for students who self-identified as African American, Asian or Pacific Islander, or other than for non-Hispanic White and Hispanic students across 20 physical therapy education programs.¹⁴ Additionally, Cook et al¹⁵ found that less programmatic racial diversity was associated with higher pass rates across 185 Commission on Accreditation in Physical Therapy Education–accredited programs.

Athletic training may be no exception to these achievement gaps. Previous researchers have highlighted the achievement gap in Board of Certification (BOC) pass rates, which is worrisome. The BOC has reported the first-time and overall 3-year aggregate pass rates of African Americans as 22.6% and 23.4% lower, respectively, than those of White candidates during the 2017–2018 through 2019–2020 examination cycles.¹⁶ Furthermore, the authors¹⁶ of a recent study of a single professional master's athletic training program observed the 3-year aggregate of first-time BOC pass rates during the same 3-year interval was only 70.5% (n = 24/34). A closer examination of these data revealed that, of the 10 students who failed the BOC examination on the first attempt, 70% (7/10) identified as non-White.¹⁶ To our knowledge, no current literature exists beyond the case study by Adams et al,¹⁶ who investigated the potential relationship between ethnicity and BOC examination pass rates across athletic training programs. Therefore, the purpose of our research study was to address the following research question: In professional master's candidates challenging the BOC examination, what was the relative risk of failure between White candidates and those from underrepresented minority groups? We hypothesized that ethnicity serves as a sociocultural barrier to successfully challenging the BOC examination, subsequently affecting the social and economic mobility of athletic training program graduates and the diversity of the athletic training workforce.

METHODS

We used a nonexperimental, descriptive, retrospective analysis to examine first-time and unsuccessful attempts at the BOC examination with respect to ethnicity.

RESULTS

Among the 4425 attempts, 3372 of 3742 candidates achieved first-time success (overall first-time pass rate = 90.1%), and 372 candidates experienced 683 retake attempts (range = 1–13). Most first attempts were taken on content from PA6 (60.8%, 2274/3742), during the 2019–2020 year (21.0%, 786/3742) and examination window 1 (April; 59.7%, n = 2234/3742). Most first-attempt examination candidates self-identified as White (60.4%, n = 2261/3742), unknown (ie, withheld an ethnicity selection; 10.6%, n = 395/3742), Hispanic (8.6%, n = 320/3742), or African American (8.4%, n = 313/3742) ethnicity. On average, the ethnic diversity of first-attempt examination candidates increased from the 2011–2012 to the 2019–2020 exam cycle (Figure 1).

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We identified that, on the first attempt, White students passed at a rate of 93.2% (2107/2261), African American students at a rate of 74.8% (234/313), and Hispanic students at a rate of 86.9% (278/320; the overall first-time pass rate for this subsample = 90.5%, 2619/2894). The relative risk of first-attempt failure was higher for African American students (relative risk = 3.706, 95% CI = 2.903, 4.730; P < .001) than White students. The risk of failure was also higher for African American candidates than for Hispanic candidates on the first attempt at the examination (relative risk = 1.923, 95% CI = 1.368, 2.703; P > .001). For Hispanic students, the relative risk of first-attempt failure was about 50% lower than for White students (relative risk = 0.519, 95% CI = 0.377, 0.715; P < .001). A χ² test of independence showed a significant association between practice analysis and ethnicity (\(\def\upalpha{\unicode[Times]{x3B1}}\)\(\def\upbeta{\unicode[Times]{x3B2}}\)\(\def\upgamma{\unicode[Times]{x3B3}}\)\(\def\updelta{\unicode[Times]{x3B4}}\)\(\def\upvarepsilon{\unicode[Times]{x3B5}}\)\(\def\upzeta{\unicode[Times]{x3B6}}\)\(\def\upeta{\unicode[Times]{x3B7}}\)\(\def\uptheta{\unicode[Times]{x3B8}}\)\(\def\upiota{\unicode[Times]{x3B9}}\)\(\def\upkappa{\unicode[Times]{x3BA}}\)\(\def\uplambda{\unicode[Times]{x3BB}}\)\(\def\upmu{\unicode[Times]{x3BC}}\)\(\def\upnu{\unicode[Times]{x3BD}}\)\(\def\upxi{\unicode[Times]{x3BE}}\)\(\def\upomicron{\unicode[Times]{x3BF}}\)\(\def\uppi{\unicode[Times]{x3C0}}\)\(\def\uprho{\unicode[Times]{x3C1}}\)\(\def\upsigma{\unicode[Times]{x3C3}}\)\(\def\uptau{\unicode[Times]{x3C4}}\)\(\def\upupsilon{\unicode[Times]{x3C5}}\)\(\def\upphi{\unicode[Times]{x3C6}}\)\(\def\upchi{\unicode[Times]{x3C7}}\)\(\def\uppsy{\unicode[Times]{x3C8}}\)\(\def\upomega{\unicode[Times]{x3C9}}\)\(\def\bialpha{\boldsymbol{\alpha}}\)\(\def\bibeta{\boldsymbol{\beta}}\)\(\def\bigamma{\boldsymbol{\gamma}}\)\(\def\bidelta{\boldsymbol{\delta}}\)\(\def\bivarepsilon{\boldsymbol{\varepsilon}}\)\(\def\bizeta{\boldsymbol{\zeta}}\)\(\def\bieta{\boldsymbol{\eta}}\)\(\def\bitheta{\boldsymbol{\theta}}\)\(\def\biiota{\boldsymbol{\iota}}\)\(\def\bikappa{\boldsymbol{\kappa}}\)\(\def\bilambda{\boldsymbol{\lambda}}\)\(\def\bimu{\boldsymbol{\mu}}\)\(\def\binu{\boldsymbol{\nu}}\)\(\def\bixi{\boldsymbol{\xi}}\)\(\def\biomicron{\boldsymbol{\micron}}\)\(\def\bipi{\boldsymbol{\pi}}\)\(\def\birho{\boldsymbol{\rho}}\)\(\def\bisigma{\boldsymbol{\sigma}}\)\(\def\bitau{\boldsymbol{\tau}}\)\(\def\biupsilon{\boldsymbol{\upsilon}}\)\(\def\biphi{\boldsymbol{\phi}}\)\(\def\bichi{\boldsymbol{\chi}}\)\(\def\bipsy{\boldsymbol{\psy}}\)\(\def\biomega{\boldsymbol{\omega}}\)\(\def\bupalpha{\bf{\alpha}}\)\(\def\bupbeta{\bf{\beta}}\)\(\def\bupgamma{\bf{\gamma}}\)\(\def\bupdelta{\bf{\delta}}\)\(\def\bupvarepsilon{\bf{\varepsilon}}\)\(\def\bupzeta{\bf{\zeta}}\)\(\def\bupeta{\bf{\eta}}\)\(\def\buptheta{\bf{\theta}}\)\(\def\bupiota{\bf{\iota}}\)\(\def\bupkappa{\bf{\kappa}}\)\(\def\buplambda{\bf{\lambda}}\)\(\def\bupmu{\bf{\mu}}\)\(\def\bupnu{\bf{\nu}}\)\(\def\bupxi{\bf{\xi}}\)\(\def\bupomicron{\bf{\micron}}\)\(\def\buppi{\bf{\pi}}\)\(\def\buprho{\bf{\rho}}\)\(\def\bupsigma{\bf{\sigma}}\)\(\def\buptau{\bf{\tau}}\)\(\def\bupupsilon{\bf{\upsilon}}\)\(\def\bupphi{\bf{\phi}}\)\(\def\bupchi{\bf{\chi}}\)\(\def\buppsy{\bf{\psy}}\)\(\def\bupomega{\bf{\omega}}\)\(\def\bGamma{\bf{\Gamma}}\)\(\def\bDelta{\bf{\Delta}}\)\(\def\bTheta{\bf{\Theta}}\)\(\def\bLambda{\bf{\Lambda}}\)\(\def\bXi{\bf{\Xi}}\)\(\def\bPi{\bf{\Pi}}\)\(\def\bSigma{\bf{\Sigma}}\)\(\def\bPhi{\bf{\Phi}}\)\(\def\bPsi{\bf{\Psi}}\)\(\def\bOmega{\bf{\Omega}}\)\({\chi^2_{{\rm {df}}\ =\ 1}}\) = 88.367; P < .001; Figure 2) as well as examination cycle and ethnicity (\({\chi^2_{{\rm {df}}\ =\ 1}}\) = 76.408; P < .001; Figure 3). The transition from the PA6 to the PA7 version of the examination appeared to affect all candidates poorly but no one ethnic population more than another.

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When students pursued an examination retake, the relative risk of failure was 34.1% higher for African American students than for their White counterparts (relative risk = 1.341, 95% CI = 1.141, 1.575, P < .001), while Hispanic students fared better on retake attempts (relative risk of failure = 0.854, 95% CI = 0.685, 1.065; P = .179) than White students. African American students had a higher risk of failure on retake attempts than Hispanic students (relative risk = 1.145, 95% CI = 0.929, 1.412; P = .183).

DISCUSSION

To our knowledge, we are the first to investigate the relative risk of failure on the BOC examination among ethnicities. Disparities existed in BOC examination performance that specifically hindered African American and Hispanic candidates from obtaining the certified athletic trainer credential and subsequently entering the athletic training workforce. Of particular concern is the fact that these achievement gaps persisted over the last decade as the number of professional master's athletic training programs increased more than 6-fold. Achievement disparities showed no signs of diminishing as programs continue to transition to professional education at the master's level. Even more worrisome is the acknowledgment that the acceleration of online and remote education secondary to the COVID-19 pandemic carries the rick of widening the existing achievement gaps. In addition to other systemic barriers, students from underrepresented minority groups often suffer from a digital divide due to unequal access to digital tools and inadequate skills to use digital tools for learning purposes.¹⁷ Also, they often endure economic and structural divides that limit physical spaces to study and lack suitable instructional support from schools.¹⁷ Considering the increased reliance on online and distance education models, these findings warrant forecasting on how the achievement gaps presented might persist through the use of these educational modalities. More importantly, educators and program administrators must look toward the future and consider as well as account for how the effects of the COVID-19 pandemic may disturb readiness in students from underrepresented minority groups recruited into athletic training programs.

Initial awareness of the achievement gaps in students' educational experiences can lead to underperformance secondary to the stress and anxiety created by negative stereotypes about their racial or ethnic group. The effect of this pressure can be enough to negatively affect the student's performance and result in failure on the BOC examination. Students from a demographic minority who fail to successfully challenge the BOC examination on the first attempt may enter a perpetual cycle of psychological distress, as evident by the fact that African American students continued to have a higher risk of failure on retake attempts than White or Hispanic students. After first-time failure, candidates could internalize, externalize, or both internalize and externalize these stereotypes to further reinforce stereotype threat and challenge success on future retake examinations. Previous researchers¹⁸ have shown that candidates for the NCLEX-RN can be overcome with anguish after notification of failure.¹⁸ This distress was costly to the individuals' psychosocial well-being. Specifically, candidates who failed the NCLEX-RN reported negative emotions, including feelings of loss and inadequacy as well as depression and isolation.^19,20 Such feelings of depression and isolation present psychological health concerns for any candidate but especially for the candidate from an ethnic minority group who is more likely to delay or fail to seek mental health treatment and less likely to have access to needed mental health services and quality mental health care.²¹ In addition to these obstacles, a lack of employment may hinder a candidate's access to health insurance coverage and affordable behavioral health care. Moreover, feelings of embarrassment, loss, and social stigma and decreased self-esteem have also been described after failing the NCLEX-RN.²² Similar to graduate nurses, athletic training candidates may then begin to suffer guilt over disappointing their professors, preceptors, peers, family members, or all of these and thus avoid seeking their assistance in preparation for retake examinations. Collectively, these feelings and emotions coupled with stereotype threat may prevent further goal attainment.¹⁸

The benefits of social mobility and economic opportunities obtained from higher education cannot be achieved without successfully challenging the BOC examination. Failure on the BOC examination also presents challenging economic consequences to the individual candidate seeking athletic training certification. Candidates who fail the BOC examination on the first attempt and retake the examination must pay the $330 fee again.²³ Aside from the cost of another examination registration, many retake candidates incur the additional costs of remediation strategies such as the purchase of additional practice examinations, review courses, and study materials to avoid another failure.¹⁸ Furthermore, retake candidates must wait until the next available examination window.²³ This waiting period can further delay students' transition to clinical practice and postpone their employment status as ATs. Delays in employment status may result in lost salary and the expected return in investment after graduation for candidates who have devoted substantial capital to tuition and fees at the graduate level.¹⁸ Financial strain may be exacerbated if the student becomes eligible and responsible for repayment of student loan debt after completing graduate school.^18,19 These mounting expenses are concerns for any retake candidate but are worsened by the fact that those from ethnic minority groups are more likely to have a lower median household income and lower net worth.²⁰ The risk of losing students from underrepresented minority groups occurs at many timepoints across their educational journey, including at admission and enrollment as well as with program or examination persistence and completion. We believe these factors resulting from the achievement gap on the BOC examination present further substantial barriers to the persistence of individuals from underrepresented minority groups in the athletic training profession. Highlighting athletic training achievement gaps and their resulting consequences is a foundational first step to improving pass rates and bringing well-prepared, diverse ATs into the profession.

In recent years, the Athletic Training Strategic Alliance has placed increased emphasis on the importance of equality in age, gender, sexual orientation, race, ethnicity, and other cultural factors as a mechanism for both improving diversity in the athletic training profession and enhancing the delivery of quality patient-centered care.^24–27 The National Athletic Trainers' Association has developed several groups, including the Ethnic Diversity Advisory Committee and the Diversity, Equity, Inclusion, and Access Taskforce, dedicated to addressing concerns relevant to ethnically diverse populations. The Commission on Accreditation of Athletic Training Education (CAATE) has established the Diversity, Equity, Inclusion, and Leadership Development Committee and introduced curricular content standards, which intentionally focus on the adequate incorporation of diversity, equity, inclusion, and social justice across athletic training curricula. Similarly, the BOC has created an Inclusion, Diversity, Equity, and Advocacy Strategies Task Force whose work is aimed at exploring inclusion, diversity, and equity opportunities in the BOC, including analysis and alignment of the BOC's processes for collecting demographic information from examination candidates. The work of the Strategic Alliance affirms the need for research regarding racial and ethnic inequities in athletic training. However, to date, lacking in these initiatives is a direct acknowledgment of the achievement gap that exists in athletic training education, specifically as it relates to success on the BOC examination.

Accrediting bodies such as the CAATE exist to ensure that higher education programs maintain as well as improve quality standards of education. Toward these ends, they shoulder the responsibility of ensuring athletic training programs pursue and achieve diversity in accordance with the CAATE Standards and individual institutional and programmatic mission statements. We are optimistic that the new CAATE curricular content standards will help to rectify these inequities by ensuring that classroom environments are free of discrimination; valuing inclusion in the recruitment of diverse faculty, preceptors, and students; and developing curricula that advance diversity, equity, inclusion, and social justice in professional athletic training education.²⁸ However, we echo the concerns of Adams et al¹⁶ that acknowledgment of this achievement gap in pass rates may have adverse effects on underrepresented minority groups. Pass rates of athletic training program graduates are used in Standards 6 and 7 as metrics for maintaining CAATE accreditation. In turn, programs that serve individuals from underrepresented minorities may be at risk of being placed on probation. Also, programs seeking to improve their student enrollment may develop biases against African American and Hispanic applicants, becoming less willing to accept students from these underrepresented minority groups into their programs out of fear of accreditation-related ramifications.²⁹ These possible consequences serve as problematic barriers to diversification of the athletic training profession. Removing Standards 6 and 7 would conflict with the spirit of programmatic accountability for preparing qualified providers and diversity initiatives. However, we recommend removing the punitive nature of these standards and instead requiring programs to be transparent in efforts to both prepare students as providers and diversify our profession.

We specifically see Standard Diversity, Equity, and Inclusion (DEI) 1³⁰ as an avenue for combating these concerns and influencing programs to advance diversity, equity, inclusion, and social justice in their design and delivery. With this standard, we promote the expectation of measurable outcomes through the assembly of program data that inform these efforts. We further suggest that, as part of this standard, athletic training programs publicly post diversity statistics and inclusion efforts for each cohort on their websites so that prospective students can effectively select programs that value and honor diversity and are committed to public accountability.³¹ Standard DEI 1 provides examples of inclusion initiatives, including participating in institutional efforts to advance diversity, equity, inclusion, and social justice; integrating these concepts throughout the curriculum; and recruiting and retaining diverse faculty, students, and preceptors.³⁰ The standard further states that programs should collect data relative to demographic reports, retention reports, equity analysis, climate data, engagement in inclusion and social justice activities, and other factors.³⁰ The CAATE defines identities as inclusive of but not limited to race, ethnicity, religion or spirituality, national origin, age, marital status, disability or ability, sexual orientation, sex, gender, gender identity and expression, socioeconomic status, political affiliation, and literacy or health literacy.³⁰ Programs should be encouraged to share demographic reports, including offering transparency about preparing students from minority groups to be successful in challenging the BOC examination as well as efforts to expand the diversity of their community (faculty, preceptors, and students) systematically and publicly.

Thoughtful discussion and analysis are needed within the athletic training community around this subject, though it is ultimately the roles of the BOC and the CAATE to prevent these findings from affecting athletic training program viability. Moreover, efforts to diversify the profession through open and transparent education should not dull the expectations of program accountability broadly but should include a multipronged effort. Without a doubt, programs should be training providers to be successful in challenging the examination but should also be held to public accountability by the consumer. Potential students should be able to identify exemplary programs in both diversity, equity, and inclusion and in preparing them to be successful providers.

Although top-down approaches are necessary, we also believe that grassroots efforts will be required to end the achievement gap in athletic training. Creating a diverse workforce of athletic training clinicians will require ensuring a diverse student body that is academically prepared to pass the BOC examination. We acknowledge the important role of athletic training programs in this mission. Previous researchers³² revealed that athletic training program directors lacked the awareness needed to distinguish between equitable and equal resources. When it comes to diversity and inclusion, most program administrators took a “color-blind” approach, expressing the belief that all students should be treated the same, regardless of their ethnicity.³² This ideology invalidates the specific needs of students from ethnic minority groups.³² Athletic training programs must take ownership in the success of all students. This includes making intentional efforts to help candidates from ethnic minority groups assess and remediate their individual weaknesses and prepare for future attempts at the BOC examination, not only supporting them while part of the program but also after matriculating from their formal education if necessary. Although we do not assume that all students from ethnic minority groups will perform poorly on the BOC examination, we do expect that educators should understand the circumstances from which many athletic training students from ethnic minority groups enter professional programs and the consequences that result from persistent achievement gaps.

We seek to highlight the importance of this topic, yet we acknowledge that this study was not without limitations. Primarily, candidates were categorized using social constructs that may or may not accurately identify an individual's race, ethnicity, or cultural identity. The use of preselected options to collect data helped to create consistency in how candidates selected their ethnicity. However, in turn, it failed to provide an encompassing list of all available ethnic identities. Furthermore, a noteworthy number of candidates (10.6%, n = 395/3742) in the participant sample chose to withhold their ethnicity and were classified as unknown. We suspect that some candidates did not feel adequately represented by the list and preferred not to answer the question, whereas others may have been concerned about the potential for biased score reporting and stereotype threat. Future prospective data collectors should consider when these data are collected (ie, during registration, before or after the examination) and allow candidates to self-describe ethnicity. As the profession grows, common text field responses should be analyzed to expand self-report selection categories to reflect diverse candidate identities.

CONCLUSIONS

We explored the relative risk of failure on the BOC examination by ethnicity. We concluded that significant achievement gaps existed between African American candidates and White and Hispanic candidates on both initial and retake attempts. The consequences of examination failure include financial strain, psychological burden, potentially delayed transition to the workforce, and decreased retention in the athletic training profession. Future researchers should assess the effects of the COVID-19 pandemic on existing achievement gaps and encourage thoughtful discussion in addition to analysis of how these results may affect admission standards and program viability. Diversification of the athletic training workforce will require ensuring equity in preparation for and success on the BOC examination. We illuminate the achievement gap in success on the BOC examination not to exclude these students from athletic training recruitment efforts but to promote public accountability for taking action to assist candidates from underrepresented minority groups in successfully challenging the BOC examination and transitioning into the athletic training workforce.