Athletic Trainers’ Familiarity, Comfort, Knowledge, and Recognition of Social Determinants of Health

Participants

Certified ATs who were members of the National Athletic Trainers’ Association (NATA) in good standing were eligible to participate in the study. Athletic trainers in various settings and positions and at various education levels were included in this study to ensure that the results reflected the broad perceptions of ATs. Using convenience sampling, we drew potential participants from across the United States using the NATA Survey Research Service.

Instrumentation

The Athletic Trainers’ Perceptions of Social Determinants of Health Survey (AT-SDH) was used to evaluate ATs’ familiarity and comfort with SDOH as well as their perceived knowledge and recognition of SDOH. The survey was adapted from 2 previously validated surveys that were used to evaluate SDOH in a health department residency population.^15,16 A variety of question types were used in the survey, such as Likert-type scales, multiple choice, and multiselect. Perceived familiarity and comfort with and knowledge about SDOH were assessed using a 4-point Likert-type scale (ie, not familiar at all, minimally familiar, moderately familiar, extremely familiar). All perception questions followed a similar format. For example, we evaluated comfort by asking, “How comfortable are you with identifying the SDOH?” and general knowledge by asking, “How knowledgeable are you about the [SDOH]?” Recognition of SDOH was assessed by having ATs identify SDOH items from a list of examples of SDOH, structural inequalities, and other constructs. In the list, SDOH were education, employment, health systems and services, housing, income and wealth, physical environment, public safety, social environment, and transportation.³ Structural inequalities included class, gender, racism, and sexism. Other constructs were genetics, health behavior, and psychosocial characteristics. Demographic information of respondents was also requested. The survey was distributed on the Qualtrics management software platform (Qualtrics, Inc).

We reassessed content and face validity for our survey. Two content and survey design experts completed an established validation rubric¹⁷; each expert is a PhD-trained researcher with more than 15 years of experience conducting health care research. One individual has extensive expertise designing and conducting survey research, and the other has published research related to SDOH. Based on their feedback, we made minor updates to the survey. To ensure clarity and comprehension of the survey items, 19 pilot participants who met our inclusion criteria for the study completed the survey; their data were not included in our final analyses. Based on pilot participant feedback, no additional edits were made to the survey. Thus, the final AT-SDH survey consisted of 45 questions that assessed ATs’ familiarity and comfort with SDOH and their perceived knowledge and recognition of SDOH. Skip logic was used, so the total number of survey questions varied by respondent. The AT-SDH survey was designed to take 10 to 15 minutes to complete.¹⁸

Procedures

Via the NATA Survey Research Service, we identified 17 000 certified ATs who met the study inclusion criteria. During September 2019, an invitation to the survey was emailed to potential participants. The email explained the purpose of the study, provided the expected time for completion, and listed contact information for the research team. Participants were informed that they provided their consent by voluntarily completing any portion of the survey. A reminder email was sent every week during the 4-week data-collection period to those who had not yet completed the survey.

Data Analysis

Due to the exempt nature of survey research, respondents were not required to answer every item in the current survey. We included partial and complete survey responses in the data analyses. Descriptive statistics, including means, SDs, frequencies, percentages, medians, and interquartile ranges, were calculated to summarize the survey data. An index of SDOH recognition was computed to offset inflation of scores by guessing. The percentages of correct response endorsements of the social determinant of health recognition question and incorrect response endorsements were calculated for each respondent; the percentage of incorrect responses was then subtracted from the percentage of correct responses.¹⁹ Percentages, rather than counts, were used to report recognition findings because the scale was imbalanced with regard to correct (9) and incorrect (7) items. A higher composite score indicated greater recognition. Specifically, a negative score indicated that the respondent endorsed a higher percentage of incorrect than correct responses, whereas a positive score indicated the endorsement of a higher percentage of correct than incorrect responses. Statistical analyses were performed using SPSS (version 26; IBM Corp).

Familiarity and Comfort With SDOH

Few ATs reported being extremely familiar or comfortable with the concept of SDOH; at best, ATs were minimally to moderately comfortable. This finding was not surprising given that SDOH are a recent addition to educational standards in athletic training,¹² and most of the respondents had been practicing for an average of 15 years and may not have received specific training on this concept. In contrast, health care providers in community health centers described being very familiar with SDOH.¹⁵ Although the difference between the familiarity of providers in athletic health care and those who work in community health centers is unknown, some differences in the practice should be considered. Community health centers are designed to provide greater access to patients and may more frequently support patients with lower incomes and state-issued insurance and serve patients with a variety of general medical conditions. Many ATs do not bill for their services and work independently, reducing the opportunity for interprofessional interactions across health specialties. Also, they tend to focus on athletic injuries, potentially limiting their familiarity and comfort with SDOH. Increasing ATs’ familiarity and comfort with SDOH may assist in greater recognition of these factors in their patients, which is a starting place for managing these factors and referring patients as a part of care. Athletic trainers may not be able to address all SDOH themselves, but providing information about resources, such as food pantry distribution centers and referral to community services, is within ATs’ scope of practice.

Informal workplace learning is one opportunity for increasing familiarity and comfort with SDOH. For example, Joynes et al²⁰ described triggers for informal workplace learning, including awareness of patient needs and exposure to the practices and policies of other health care professionals. In previous studies,^21–23 when health care providers had experience with or were exposed to injuries, illnesses, and disabilities, their comfort in diagnosing, treating, and caring for certain patients increased. Ensuring that ATs are exposed to patients experiencing negative influences of SDOH is important and should be coupled with the purposeful integration of SDOH assessment into practice. One example of a purposeful integration is to include a screening tool for SDOH, such as the American Academy of Family Physicians Social Needs Screening Tool,²⁴ into preparticipation physical or standard injury evaluations. With the knowledge that SDOH can negatively influence athletes under their care, ATs can begin to improve their clinical management and care decisions. Athletic trainers may consider including school psychologists, social workers, and teachers to tackle negatively influencing SDOH where appropriate, further promoting whole-patient care.

Among health care providers, including ATs, training or educational interventions have been suggested to increase comfort and familiarity with SDOH.^25–28 For example, Freiburger et al²⁷ implemented a 3-part SDOH learning activity for postprofessional athletic training students with the goal of increasing student knowledge and promoting recognition of these factors in practice. Preintervention versus postintervention results suggested that the students improved their familiarity and comfort with identifying SDOH at the point of care as a result of this educational technique.²⁷ Educational techniques, such as those described by Frieberger et al,²⁷ have the potential to influence the familiarity and comfort of future ATs, yet additional ideas and strategies are needed to support clinicians who completed their education before the change in educational standards. A critical consideration is how to translate the knowledge about SDOH to use in clinical practice. Researchers have proposed that a learner who develops a positive attitude toward the concept is more likely to translate the new knowledge to practice.¹⁴ Only when clinicians find value, familiarity, and comfort in a concept will attitudes and behavior change to advance the integration of said concept into practice.¹⁴ Continued efforts to include SDOH in educational programs and continuing education opportunities should be a professional priority to increase the uptake of knowledge and translation to practice.

Knowledge and Recognition of SDOH

Winkelmann et al²⁹ assessed the actual knowledge of ATs regarding various public health topics, including SDOH. Athletic trainers performed poorly on SDOH items.²⁹ In our study, approximately 60% of ATs perceived that they had no or minimal knowledge of SDOH. Despite this perception about SDOH, more than half of ATs endorsed 8 of the 9 listed SDOH in the survey, and 22% endorsed more correct than incorrect items, which suggests some level of SDOH recognition without strong feelings of knowledge about these factors. Although recognition of factors described on a survey may not directly translate to recognition in practice, this information is a start to understanding ATs’ perceptions of the complex construct of SDOH. Athletic trainers recognize SDOH in a broad sense. Recognition in the real world with complex patient cases warrants further investigation.

Similar to our findings, previous researchers in athletic training have found that perceived knowledge³⁰ and confidence in knowledge³¹ did not always correlate with actual knowledge. Additionally, ATs have noted lack of knowledge as a barrier to implementing other critical concepts, such as evidence-based practice, into educational programming and practice.^32,33 The inclusion of SDOH content in professional athletic training education has progressed, but continuing education resources and opportunities are necessary to promote profession-wide adoption of SDOH as an important component of whole-person health care.

Clearly, clinician exposure to SDOH and education related to SDOH are not enough to improve the overall health and well-being of patients. However, the recognition of SDOH by ATs can be beneficial. Athletic trainers are in a unique position to identify and refer patients who may need additional support caused by the negative influence of SDOH. For instance, because ATs often have regular interactions with their patients, improving their abilities to recognize those who may be vulnerable to the negative influence of SDOH can help identify resource needs within specific patient communities. Given that these factors matter more to the health of patients than the health care provided,^3,4,6 the need to address SDOH is clear. Therefore, beginning to assess or screen for SDOH in athletic training practice may increase familiarity and comfort with SDOH at the point of care and fill knowledge gaps. When clinicians screen for SDOH and provide guidance, the health and satisfaction of patients improve,³⁴ patients make fewer visits to the emergency room, and prescription medications for environmental-related conditions decrease.^35–37 Authors who evaluated the implementation of a screening tool for SDOH in primary care determined that 92% of clinicians reported screening was beneficial to their patients, and 96% supported continued use of the screening tool.³⁸ Successfully addressing upstream SDOH is a complex process and requires an approach that includes all health care providers, organizations, communities, public health activists, and policymakers. Only by including all interested parties can benefits at the population level be actualized. Because ATs are often the first health care providers to interact with patients, the athletic training profession needs to more fully consider assessment of SDOH before we can begin to address negatively influencing social factors at an individual level.

Limitations

Our results should be interpreted in the context of their limitations. The survey access rate was low; however, the gender and age of our participants were similar to recently reported AT demographics by the Board of Certification (https://bocatc.org/system/document_versions/versions/293/original/at-demographics-20220414.pdf?1649950857). Among potential participants who accessed the survey, almost all completed it. Those who accessed the survey were probably more likely than other ATs to be interested in SDOH. Additionally, the survey was open to ATs who were educators and researchers, as they will be the ones to educate future ATs. As such, the findings of this study may overestimate the interest and perceived knowledge about SDOH in the AT community. We assessed recognition of SDOH using a single multiselect question, which limited the ability to explore ATs’ recognition of the full range of complexities associated with this broad concept. Given that the survey was intended as a foundation for future research in this area, results from the recognition question should be considered a starting point to gauge basic SDOH knowledge. Finally, these data were collected in 2019, before distinguishing world events. Global phenomena, including the COVID-19 pandemic and numerous events highlighting social injustice concerns, have garnered media attention to social inequity and SDOH. How these events may have affected the perceptions and knowledge of ATs regarding SDOH is unknown, but ATs’ perceptions and knowledge of SDOH may have increased since the current study. Future researchers should investigate which SDOH are commonly encountered by ATs at the point of care in a variety of settings. Ideally, such information would promote the assessment of SDOH in patient care and provide ATs with the necessary resources to mitigate the negative influence of SDOH.