Youth Athletes' Parents' Perceptions and Knowledge of the Athletic Training Profession

Procedures

This study was part of a larger investigation examining key stakeholders' perceptions and knowledge of the profession of athletic training. We used a concurrent mixed-methods research design via a cross-sectional online questionnaire to gather information regarding parents' knowledge and perceptions of athletic training. Due to the challenges associated with accessing a large, diverse sample of parents, we contacted the USA Football organization to discuss survey distribution options to their parent affiliates. The national governing body for amateur American football, USA Football oversees the sport experience for youth and high school athletes. To ensure privacy and confidentiality, as well as abide by the rules of the organization, the distribution method of choice was for USA Football to distribute the survey link to parent contacts in their database on our behalf. The link to the survey (Qualtrics International Inc) was sent to all 10 763 parents in June 2017 upon approval from the University of Connecticut Institutional Review Board.

Instrument Development and Validation

To remain consistent across groups being studied as part of the larger investigation, the questionnaire used for the legislator,⁹ athletic director,¹⁰ and principal¹¹ populations served as the foundation for the parent-specific questionnaire. Although a majority of the questions were identical to past versions of the questionnaire, we removed items pertaining to secondary school or district administration (eg, liability reduction, cost savings, AT employment details) to better align content to the role of the parent. The survey was developed by 2 members of the research team, with input from another AT. Knowledge and previous experience working clinically as ATs and as educators in an athletic training program served as the primary facilitators of questionnaire development. After an initial draft, the questionnaire was thoroughly reviewed by leadership in the marketing department at the NATA. The final instrument was composed of 3 sections: (1) respondent demographics (9 questions); (2) quantitative items evaluating parents' perceived value and knowledge of the roles, skillset, and value of an AT (16 items with branch questions as applicable); and (3) open-ended questions allowing parents to expand on their opinions and beliefs (4 questions). The quantitative items in section 2 were guided by the practice analysis (7th edition, Board of Certification for the Athletic Trainer).¹² Open-ended questions were as follows: (1) How do you feel having an AT at the school could/does impact your child's health and safety? (2) In your opinion, what is an AT? (3) What are the outlined job responsibilities of an AT? and (4) What do you believe are the minimum requirements (educational and certifications) to become an AT?

We used 2 procedures¹³ to validate the survey before it was distributed. Three parents with children who were currently or previously in high school reviewed the instrument to provide feedback on the clarity, relevance, and importance of each question to the overall intent of the study. For the purpose of face validity, clarity meant that the question was easily understood for both content and intent. Relevance indicated that the question was meaningful to achieve the study's purpose. Lastly, importance referred to the degree to which each question was critical to achieving the study's purpose. Each item (clarity, relevance, importance) was measured on a 4-point scale (eg, 1 = not relevant, 4 = highly relevant). If rated ≤2 by a majority of the reviewers in relevance or importance, the question was removed from the final instrument. Items lacking clarity were edited based on the feedback provided to ensure content validity. Finally, a member of the research team completed the survey online to review it for flow and correct any errors that would invalidate the results (eg, grammar, display logic, single versus multiple answer).

Quantitative Data Analysis

Quantitative data were analyzed using SPSS (version 25; IBM Corp). We calculated descriptive statistics for the demographic data via this software, which were reported as means and SDs along with frequencies in the form of percentages when appropriate. Count and percentage responses for select quantitative items were obtained through the report feature in the Qualtrics platform.

We were also interested in determining if relationships existed between overall perceptions of ATs and various demographic variables. Due to nonnormal distribution of the data (Kolmogorov-Smirnov values <0.001 for all variables) and dichotomous variables of interest, we used χ² to test for associations between perceptions based on respondents who previously knew an AT versus those who did not, as well as respondents who participated in high school or collegiate athletics (or both) versus those who did not. Odds ratios with 95% CIs were calculated using 2 × 2 contingency tables to compare the relative odds of selecting specific survey response options based on the dichotomous variables outlined above. The α level of significance was set at P < .05 for all analyses.

Qualitative Data Analysis

We analyzed open-ended responses using the general inductive approach¹⁴ to allow trends in the data to naturally emerge through the analysis. Two research team members independently analyzed the data, which entailed assigning codes to pieces of text that related to the purpose of the study. Similar codes were combined to form categories, which were then defined to become the emerging themes in the data. After individual analyses, the 2 members discussed their coding procedures and overall impressions via telephone communication until a consensus was reached. This process, known as multiple-analyst triangulation,¹⁵ was 1 method of enhancing trustworthiness in the qualitative research findings. Simultaneous triangulation of the quantitative and qualitative data served as our second credibility strategy. The use of quantitative measures and open-ended items in the questionnaire allowed for the collection of complementary data¹⁶ to strengthen our understanding of parents' perceptions and knowledge of the profession.

Demographics

Of the 10 763 parents to whom the questionnaire was administered, 521 accessed it, with 390 completing it in full. Despite this low response rate (n = 390/10 763, 3.6%), our data were representative of a 74.8% (n = 390/521) completion rate. Of the 390 responses, 316 respondents indicated they had a child in high school, either previously or at the time of survey completion, which was required to be included in the data analysis. The Figure includes a schematic for the determination of this response rate. A total of 36 states were represented (Table 1). Demographic data for the respondents are presented in Table 2. We had a relatively even split between men (n = 169, 53%) and women (n = 146, 46%). The average age of our respondents was 45.6 ± 6.2 years (n = 291). Interestingly, 18% (n = 57) of respondents held at least 1 medical certification, and approximately 29% (n = 84) were previously asked to provide medical care at a sporting event.

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Table 1 Respondents by State

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Table 2 Respondent Demographics

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Perceived Value of ATs

Responses to both open-ended and closed-ended survey questions shed light on the parents' perceived value of ATs and their role in maximizing student-athlete health and safety. Specifically, parents in our sample consistently discussed how having an AT present at their child's school made them feel better about their child's safety. When asked how an AT employed at their child's school could or did impact the safety of their child, responses included, “I feel like it is very important; I am glad they require one at the schools now,” “I feel comfortable leaving my child in his hands,” and “We feel more comfortable that he is available at every practice and game as well as before school and after if needed because of an injury.” Another parent stated,

I feel that having an athletic trainer at the school provides comfort to both players and parents. At my son's school, the athletic trainer is always in the weight room and on the field at all times. This provides a huge level of comfort to the parents and players.

Other parents specifically stated how they felt comfortable having a person at the school who was there to make medical decisions, so that it was not left up to the coaches. As one parent said,

The athletic trainer is empowered to overrule coaches and the athletic director for the child's health[. T]herefore, I believe my child's safety is placed above competition, which is excellent.

This was echoed in the comments of another parent:

I think the athletic trainer greatly impacts my children's health and safety. They [my children] both feel comfortable going to the [athletic] trainer when they [are] hurt and the coaches have no problem sending the kids to the [athletic] trainer to help with aches and pains. The coaches understand that the [athletic] trainer is helping to keep their athlete on the field/court. The [athletic] trainer also has a great influence on the kids. The kids really listen to what he has to say to help keep their bodies healthy and working for them.

The overall impression was that parents felt better knowing there was someone available to look out for the health and well-being of their children. “It is comfortable as a parent to know there is always going to be someone there if our child needs to be looked at.” More than 50% of parents in our sample indicated that a medical professional present at practice and competitions was a top sport safety measure, and 32.6% of respondents selected athletic trainer employed at the school as a top sport safety measure (Table 3). Interestingly, a relationship was present between personally knowing an AT (or not) and selecting athletic trainer employed at the school as a top sport safety measure (Pearson χ² = 7.096, P = .008). Parents who previously knew an AT were almost 2 times more likely to consider an AT employed at the school as a top sport safety measure compared with parents who did not personally know an AT (odds ratio = 1.955; 95% CI = 1.190, 3.214; P = .010). Additionally, more than 67% of parents believed that ATs were a trusted source of medical information. When asked directly, a large majority of parents (93%) described ATs as extremely or very valuable to the health and safety of student-athletes (Table 3). From a monetary value perspective, almost half of the respondents suggested that full-time ATs should be paid at least $50 000, with 21.2% specifically selecting greater than$60 000.

Table 3 Parents' Knowledge and Perceived Value of Athletic Training

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Knowledge of ATs' Roles and Responsibilities

We asked participants to indicate what they believed ATs were qualified to do, and more than half identified ATs' roles in return-to-play decisions, injury evaluations, emergency care, rehabilitation of injuries, first aid and wound care, and injury prevention (Table 3). Parents (63%) also cited the role of an AT in maximizing performance. Most notably, parents shared sentiments about the immediacy of care ATs provided to their children. Responses included, “I feel there is someone there to help my child with injuries immediately,” “I think having a[n athletic] trainer there gets the athlete the immediate attention the injury may need,” and “It's good to have someone provide immediate care.” Other parents were more direct in addressing particular components of the AT role, such as triage and referral. One parent wrote,

It helps having a qualified person they can go to that can focus on immediate concerns/issues and start a triage and care[,] then refer them to other appropriate medical staff.

Some parents even gave specific examples of an AT providing immediate care to their children.

[Having an AT present has a] Big impact. The athletic trainer was on the spot when my son had a concussion blow at spring practice with no football helmet on. They recognized his signs and took action. He received immediate care and I was notified in a timely manner. They put in their concussion protocol for him. This lasted weeks and they were in contact with his physician for release to start the reentry protocol back to working out/monitoring. I feel there was great support and overview with a plan in place to handle and react to the situation. [The AT did a] Very good job.

These examples were echoed by other parents:

The [athletic] trainer has been there to treat my son's ankle & finger injuries. He was also there immediately and help[ed] me through treatment and follow[-]up of my son's concussion.

Although parents in our sample had a general understanding that ATs provided immediate care for various injuries and illnesses and appreciated the on-site presence of a medical professional, they also discussed specific skills and qualifications of ATs in their responses, such as triage, making referrals, early recognition of signs and symptoms, treatment, rehabilitation, and overseeing the return-to-play process.

Value

The parents of youth student-athletes valued the athletic training profession when asked directly and through their responses to various open-ended questions. Our results allowed us to quantify the number of parents who perceived ATs to be not at all valuable to extremely valuable and gain a deeper understanding of what they found most valuable about an AT. Based on our qualitative findings, the greatest value for parents was 2-fold: (1) the presence of an AT provided parents with peace of mind and comfort and (2) they saw value in the presence of a health care professional to immediately provide care to student-athletes if and when they were injured. The synergy of these 2 values is important. The immediacy of care aspect an AT provides contributed to a sense of security and comfort for parents, knowing their child would be taken care of. This may explain why more parents selected medical professional present at practices/competition than athletic trainer employed at the school as a top safety measure.

Our finding that a majority of parents did not consider an AT employed at the school as a top safety measure compared with other more frequently selected measures, such as injury-prevention programs and protective equipment, should be explored further. Parents indicated that a medical professional present at practices and games was a top sport safety measure. Parents' emphasis on the general presence of a medical professional over an AT employed at the school may have reflected previous experience. Simply having an AT employed at the school did not guarantee that an AT or another medical professional would be present at practices or competitions. Parents clearly wanted someone on-site (AT or otherwise) to provide medical care to their children when they needed it. Our qualitative data helped support the value parents placed on having a medical provider present to immediately address the needs of student-athletes. Parents consistently discussed having an AT present at games and practices as producing a positive impact on their child's safety. We did not specifically ask our respondents if they considered an AT to be a medical professional, yet the majority described an AT as a trusted source of medical information, and the open-ended responses seemed to point to this as well.

Previous authors^10,11 who examined secondary school administrators' perceptions of top safety measures offered an interesting contrast to the parents' perceptions. Only 33.8% of athletic directors identified a medical professional present at practices and competitions as a top safety measure, with preparticipation physical examinations, AT employed at the school, injury-prevention programs, and emergency action plans all receiving more responses.¹⁰ Similarly, 32.6% of principals cited a medical professional present at practices and competitions as a top safety measure, with injury-prevention programs, preparticipation physical examinations, AT employed at the school, and protective equipment rated as top safety measures more frequently.¹¹ These differences may illuminate stakeholder-specific priorities while also possibly highlighting the value of a parent as an advocate for ATs. Top safety measures for administrators, unsurprisingly, were mostly related to administrative measures and strategies for mitigating risk and reducing liability. Parents also selected injury-prevention programs as a top safety measure, but having a person on-site to provide immediate care to their child if needed was more valuable to them than many of the administrative items deemed important by principals and athletic directors. If parents believe an AT can help keep their child safe, they have the potential to be a strong voice in advocating for hiring and retaining ATs in their children's schools.

The value parents placed on having a medical provider on-site is an avenue for professional advocates to explore further and consider using as a way to build support for AT employment. Previous researchers¹⁸ showed that parent associations had more influence on setting standards and policies related directly to their own children than professional development and teacher hiring. Additionally, the same investigators¹⁸ found that principals viewed influence from parent associations as positively impacting their own influence in establishing curriculum. Knowing that parents value having a medical provider on-site and have the most influence in regard to policy decisions that directly affect their children, national groups such as the NATA secondary school committee or “At Your Own Risk”⁶ (NATA public awareness campaign) could target education at parents and highlight the AT as a medical provider. In doing so, members of national advocacy groups can engage with a new group of advocates who will fight for the presence of ATs on the sidelines of youth sports.

Although the effect of parents advocating for the hiring of ATs is currently unknown, numerous examples exist of parents, after losing a child, becoming advocates and effectively championing change. For example, the McNair Foundation was instrumental in the adoption of the Jordan McNair Safe and Fair Play Act, which required institutions within the University System of Maryland to implement health and safety precautions for heat illness, brain injury, and rhabdomyolysis, among other conditions.¹⁹ Laurie Giordano championed the Zachary Martin Act in Florida in honor of her son who died of exertional heat stroke,²⁰ and recently, the Mangine family established the Matthew Mangine Jr. Foundation to promote awareness, education, and safety related to cardiac events in youth sports.²¹ These are just some of the many examples of parents becoming change champions and advocates for maximizing health and safety in sports.

The perceived value parents had of the AT role was also evident in their responses regarding appropriate compensation. Compared with secondary school administrators,^10,11 parents of student-athletes had higher perceptions of the worth of an AT in dollars and cents. About half of our sample selected salary ranges that aligned with or exceeded the average salary reported in the most recent NATA salary survey for a secondary school AT with athletic responsibilities²²: $52 868. Whereas 49.7% of parents selected more than $50 000, only 37.5% of athletic directors¹⁰ and 33.6% of principals¹¹ believed a sufficient salary for a full-time AT was more than $50 000. Perhaps the perceptions of AT worth among parents were positively influenced by their experiences witnessing an AT provide care to their injured child firsthand or represent the parents' lack of involvement in school budgetary decisions. This exposure of viewing an AT delivering care, as some parents described in the earlier quotes, was something that secondary school administrators may not have experienced, especially if the school in which the administrator worked did not already have an AT employed. The high regard in which parents seemed to hold ATs emphasized what passionate advocates parents could be, especially if they felt their child had received high-quality care.

For ATs, this was an important result, because direct exposure to the athletic training profession likely had a positive effect on individuals' knowledge and perceptions, especially if the exposure was a positive experience. In our sample, we saw a relationship between parents personally knowing an AT and selecting athletic trainer employed at the school as a top sport safety measure: those who knew an AT were 2 times more likely to consider AT employment a top sport safety measure compared with parents who did not know an AT. This finding may have provided support for the argument that direct exposure can positively influence individuals' overall perceptions. Parents' interactions with ATs, either through preseason meetings or one-on-one conversations stemming from their child's injury, provided insight into ATs' qualifications, skills, and responsibilities. Additional knowledge gained through these interactions can help support and promote a higher perceived value of the profession. The relationship between knowledge of ATs' roles and responsibilities and perceived value was reported previously in a sample of state legislators.⁹

Parents' lack of knowledge or awareness of the role and qualifications of an AT over and above other health care professionals who provided medical coverage for athletic events (eg, physicians, nurses, emergency medical technicians) may explain why they did not consider an AT employed at the school a top safety measure. A significant portion of parents identified strength and conditioning and maximizing performance as qualifications of ATs. Misconceptions of an AT as a “trainer” (ie, personal trainer, fitness trainer) or strength and conditioning coach was also apparent among state legislators,⁹ and although we did not directly explore this aspect, it may serve as justification for parents not considering AT employment a sport safety measure. However, this was probably not the driving factor because most respondents considered an AT a trusted source of medical information and spoke highly of their experiences with ATs in their child's school, an improvement from 2015, when 61% of parents sampled did not trust the AT's opinion 100% of the time.⁸

Vandermark et al²³ found that athletic directors most often hired emergency medical services in place of ATs in secondary schools. School administrations have also relied on coaches, based on their certifications and trainings, as well as the parents of student-athletes with occupations in the health care industry, to provide medical care instead of hiring an AT.²³ Based on our work and that of previous investigators,²³ educational efforts for parents should focus on the AT as the most appropriate and qualified health care professional to provide comprehensive medical care to student-athletes. The importance of a multifaceted approach to health care via a sports medicine team, composed of ATs, physicians, physical therapists, nurses, and emergency medical services, and the role of the AT within that team, should also be emphasized.

Knowledge

To gauge parents' understanding of the AT role, we provided a list of responsibilities based on the practice analysis.¹² Our sample of parents appeared to have a solid understanding of the more well-known or frequently seen responsibilities ATs fulfill as part of their role, such as injury prevention, wound care, and therapeutic interventions. Knowledge scores were highest among parents who had previously interacted with ATs as a result of both their own injuries and their child's injuries, compared with parents who had interactions with ATs due to 1 of the 2 aforementioned reasons and parents with no previous interactions.⁸ Direct exposure appeared to be a key facilitator for improving knowledge regarding the roles and responsibilities of ATs. This could provide an explanation for the administrative component of the AT role being basically unrecognized by our sample. If parents are not exposed to responsibilities in the Healthcare Administration and Professional Responsibility domain during their interactions with ATs, including patient care documentation, budgeting, and policy development and implementation to mitigate risk,¹² they are less likely to associate such tasks with the AT role. Therefore, educational efforts should focus on these crucial, yet often unseen, skills that ATs must possess to practice clinically.

Beyond the specific skills that comprise the AT role, parents also focused on the immediacy of care that occurred with the presence of an AT. The emphasis on immediate care was in a more global sense, irrespective of care provided during emergency situations. An AT, especially if employed full time, provides immediate care to all injured athletes, regardless of the circumstances surrounding the injury (severity, sport, emergent versus nonemergent, acute versus chronic, etc). Parents spoke more about ATs' responses to a variety of injuries (eg, concussion, musculoskeletal), not necessarily to their role in responding to immediate life-threatening situations. These injuries mirrored specific concerns related to sport participation that have been previously reported, particularly concerns with their children sustaining fractures, sprains, strains, and concussions.⁵ Seeing ATs who responded promptly and effectively to injuries that were of utmost concern to parents likely contributed to their positive perceptions of the profession, reinforcing the linkage between knowledge and value. Despite the critical role ATs played in preventing injuries and illnesses and reducing long-term sequelae, few parents asked about the availability of an AT or another qualified health care professional during practices and games.⁵

Variability in the level of knowledge our sample had regarding the full scope of an ATs' skills and responsibilities may explain why only 67.4% of respondents considered an AT to be a trusted source of medical information. Moving forward, efforts should be made to educate parents on the role of the AT in emergent and catastrophic situations, as well as an AT's skillset for evaluating injuries and illnesses and identifying differential diagnoses. This will enhance parents' understanding of the comprehensive skillset of an AT, demonstrate the importance of AT employment in secondary schools, and ultimately provide the knowledge parents need to serve as advocates for the health and safety of student-athletes during sport participation. Such advocacy includes but is not limited to inquiring about the presence of an AT at their child's practices and games, and if one is not present, having a discussion with school administrators about the importance of an on-site certified medical professional (ie, an AT) to prioritize student-athlete health and safety.

Limitations and Future Research

This study was not without limitations. Survey research may include response bias, such that parents who were most interested or knowledgeable in the topic were more apt to participate. For example, participants were gathered from a database of parents affiliated with USA Football. As football is a contact sport warranting the provision of on-site medical personnel, parents responding to the survey may have inherently had more interactions with ATs before their involvement in this study. Additionally, the response rate was 3.6%, and we only received data from parents in 36 states. Thus, the findings cannot be extrapolated to all parents with children who participated in secondary school athletics. A variety of factors can affect an online survey response rate, including the survey length and structure, outdated contact information, internet access, personal interest in the topic, follow-up communications such as reminder emails, and the presence or absence of incentives.²⁴ Although many of these factors were outside of our control (eg, the list of contacts was managed by USA Football and we were unable to send reminders due to the distribution method), it is important to consider how they may have influenced the results. For example, given the electronic method of data collection, we were unable to collect data from individuals without internet access. Additionally, because the survey was written in English, our data may not be representative of the perceptions and knowledge of parents who use English as a second language.

Regardless of these limitations, the results provided valuable insight into parents' perceptions and knowledge of athletic training. Specifically, many parents valued the profession, despite having varied knowledge of the exact roles and responsibilities. Future investigators should focus on the perceptions and knowledge of athletic training of parents in states that were not represented in this study. Additionally, similar research aimed at gathering information from parent populations outside of those affiliated with USA Football would be valuable. Data collection occurred when the professional bachelor's in athletic training degree was most prevalent, so it would be interesting and worthwhile to conduct a similar examination with the entry-level master's degree as the new standard to see if that alters parents' perceptions of the profession. Most importantly, effective means of educating parents about athletic training to further increase their perceived value and knowledge of the profession are needed as well as explorations of the effectiveness of parental groups as advocates of athletes' health and safety.