Social Determinants of Health: Considerations for Athletic Health Care

Applying the National Institute on Minority Health and Health Disparities Research Framework to Social Determinants of Health in the Context of Sport-Related Concussion: A Clinical Commentary

Sport-related concussion (SRC) is a prevalent injury. Significant disparities in SRC outcomes exist across racial and ethnic groups. These disparities may be attributed to the unequal distribution of political power (or influence) and resource allocation in various communities, shaping individuals' social determinants of health (SDOH). However, the influence of SDOH on SRC outcomes remains understudied. In this clinical commentary, we use the National Institute on Minority Health and Health Disparities Research Framework and describe how its application can help address gaps in our understanding of SDOH and SRC. This framework provides a comprehensive approach to investigating and addressing health disparities by considering SDOH along multiple levels and domains of influence. Using this framework, athletic trainers can identify areas requiring intervention and better understand how SDOH influence SRC outcomes. This understanding can help athletic trainers develop tailored interventions to promote equitable care for patients with SRC.

Become a Health Literacy Champion: Strategies to Promote Health Literacy in Athletic Training

Health literacy is defined as "the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others."1 Individuals with health disparities are more likely to have poor health outcomes and misuse health care services due to low health literacy. This connection between health literacy and health disparities demonstrates the need for clinicians to provide health literate care. Athletic trainers serve as essential points of contact for diverse patient populations in a variety of health care settings. The 2023 Practice Analysis 8 recognizes health literacy as an essential responsibility; however, few practical resources exist, and research specific to athletic training is lacking. In this manuscript, we aim to provide a primer on health literacy definitions, concepts, and best practices adapted from public health to support implementation into athletic training clinical practice.

Secondary School Athletic Trainers' Perceptions of the Influence of Social Determinants of Health and Socioeconomic Status on Clinical Management Decisions

CONTEXT

Evidence suggests that lower socioeconomic status (SES) and negative social determinants of health (SDOH) contribute to health care disparities. Due to their accessibility in the high school setting, secondary school athletic trainers (SSATs) may encounter patients who are historically underserved in health care, such as patients with low SES. However, a significant gap in knowledge exists regarding how SDOH and SES may influence SSATs' clinical management decisions.

OBJECTIVES

To describe SSATs' perceptions of how patient SDOH and SES influence clinical management decisions and to identify barriers to athletic health care.

DESIGN

Cross-sectional study.

SETTING

Online survey.

PARTICIPANTS OR OTHER PARTICIPANTS

National Athletic Trainers' Association SSATs (6.7% response rate).

MAIN OUTCOME MEASURE(S)

Secondary school athletic trainers were asked about their perceptions of patient SDOH and SES (content validity index = 0.83 for relevancy). The levels of relevance and agreement were answered on a 4-point Likert scale. Data were summarized using means and SDs, frequencies and proportions (%), and median scores.

RESULTS

A total of 380 SSATs participated (mean years of experience = 14.9 ± 11.7 years). When providing care, most (71.3%) SSATs believed their patients' health or health care access to be the most relevant of the 5 SDOH, whereas the other 4 SDOH were less than 60% relevant. Most SSATs agreed or strongly agreed that patient SES affected both referral (67.4%) and the reliance on conservative treatment before referral (71.2%). Secondary school athletic trainers identified patient or guardian compliance (70.2%) and type of health insurance (61.5%) as barriers to providing care to patients with low SES.

CONCLUSIONS

Secondary school athletic trainers perceived health or health care access as the most relevant social determinant when providing care to patients with low SES. When SSATs further considered the SES of patients, they identified all SDOH as barriers that they were ill equipped to navigate as they delivered care and engaged in patient referral.

Athletic Trainers' Observations of Social Determinants of Health in the Collegiate Setting: A Card Study

CONTEXT

Addressing social determinants of health (SDOH) in all populations improves patient outcomes, leading to better patient-centered care. Despite known influences of SDOH, little is known about the ability of athletic trainers (ATs) to observe SDOH in practice.

OBJECTIVE

To explore ATs' observations of SDOH and describe actions taken at the point of care in collegiate and university settings.

DESIGN

Descriptive via an observational card study.

SETTING

Athletic training facilities.

PATIENTS OR OTHER PARTICIPANTS

Collegiate and university ATs (23 participants across 20 institutions).

DATA COLLECTION AND ANALYSIS

The ATs used a modified observation card to document observations of SDOH during patient encounters in the collegiate or university setting. The cards contained instructions for completion and a table with 4 columns: (1) a list of 19 predetermined SDOH, (2) a checkbox for observed SDOH, (3) a checkbox for the perceived negative influence of observed SDOH on patient health, and (4) an open box to write in what actions, if any, were taken to address the observed SDOH.

RESULTS

Overall, 424 cards were collected. Of 725 observed SDOH, access to social media (153/725, 21.1%), academic stressors (131/725, 18.1%), and behavioral health issues (71/725, 9.8%) were the most commonly observed. Nearly 39% (281/725) had a perceived negative influence. Of those, academic stressors (49/281, 17.4%), behavioral health issues (46/281, 16.4%), and transportation issues (32/281, 11.4%) were most common. For the 23.0% (166/725) of SDOH acted upon, ATs used counseling and education (73/166), provided additional resources (60/166), referred to others (29/166), or communicated with others (4/166).

CONCLUSIONS

Because ATs are positioned to accurately assess SDOH, they can promote better patient-centered care and improve patient outcomes. Our results suggest that many SDOH observed by ATs in the collegiate or university setting have a negative influence on patient health. Better support for patients with academic stressors and behavioral health issues is important because of these SDOH.

The Social Determinants of Health and Athletic Trainer Availability in Indiana Secondary Schools

CONTEXT

The social determinants of health (SDOH) are circumstances under which individuals are born, work, and live that influence health outcomes. Previous researchers have examined 1 determinant of economic stability and found disparities in socioeconomic status and athletic trainer (AT) availability.

OBJECTIVE

To examine the SDOH characteristics of Indiana secondary schools and AT availability.

DESIGN

Cross-sectional study.

SETTING

Database secondary analysis.

PATIENTS OR OTHER PARTICIPANTS

A total of 426 secondary schools.

MAIN OUTCOME MEASURE(S)

All data were collected from publicly available databases. The independent variable was AT availability, and schools were classified as having a full-time AT, a part-time AT only, or no AT. The SDOH variables were gathered for each school (at the school and county levels). Data were summarized using measures of central tendencies, 1-way analysis of variance, and Kruskal-Wallis tests.

RESULTS

School enrollment was larger in schools with greater AT availability (P< .001). The proportion of non-White students was greater in schools with more AT availability (P= .002). Greater AT availability was present in counties with higher graduation rates (P= .03). Post hoc comparisons revealed differences in graduation rates between schools with a part-time AT and those with no AT (P= .04). Schools with less AT availability were located in counties with a slightly higher percentage of the population uninsured (P= .02). Schools with greater AT availability were located in counties with a higher ratio of population to primary care physicians (P= .03). Schools with less AT availability were located in counties with a higher population experiencing severe housing problems (P= .02). No differences were found in AT availability based on the 3 social and community context variables (P> .05).

CONCLUSIONS

Differences were noted in AT availability and SDOH characteristics at the secondary school level. We observed less AT availability where high school graduation rates and the population of primary care providers were lower. Strategies should be implemented to improve access to athletic health care in underresourced communities.

The Role of the Athletic Trainer in Providing Care to Transgender and Gender-Diverse Patients: Considerations for Medical Affirmation-Part II

Recently, with discriminatory legislation efforts and changing participation policies in organized sports, media attention surrounding transgender and gender-diverse (TGD) individuals has increased. These changes and the historical lack of competence and education regarding the transgender patient population have resulted in subpar patient care and a misunderstanding of the athletic trainer's (AT's) role within the health care and compliance systems. This literature review is the second part of a 2-paper series, and our objective was to educate ATs on the processes relevant to medical affirmation, including compliance considerations regarding medical eligibility, and to establish the AT's role. The gender affirmation framework includes social and legal components, which are discussed in part 1 of this literature, and the medical component is thoroughly discussed in part 2. All health care providers involved in the care of TGD individuals should work collaboratively on an interprofessional care team and have a general knowledge of the gender-affirmation process, including gender-affirming hormone therapy, surgical options, known risks and complications, and the general health needs of TGD patients. With this knowledge, ATs, as point-of-care providers and members of the interprofessional care team, are uniquely positioned to help reduce health and health care disparities. Furthermore, ATs can use their knowledge to facilitate medical compliance and eligibility in the evolving policies of sporting organizations.

Intersection of Race and Socioeconomic Status on Concussion Recovery among NCAA Student-Athletes: A CARE Consortium Study

PURPOSE

The objectives of this study are to 1) describe collegiate student-athlete (SA) race and household income and 2) evaluate time to normal academic performance (i.e., return to learn (RTL)), initiation of the return to play (iRTP) protocol, RTP protocol duration, and time to unrestricted RTP (URTP) after sustaining sport-related concussion (SRC).

METHODS

Data were collected between 2014 and 2020 by the Concussion Assessment, Research, and Education Consortium. Baseline data were used to characterize participant demographics ( N = 22,819) and post-SRC outcomes ( n = 5485 SRC) in time to RTL ( n = 1724) and RTP outcomes ( n = 2646) by race. Descriptive statistics and nonparametric tests examined differences across race by demographic and injury characteristics. Kaplan-Meier curves estimated median days to RTL, iRTP protocol, RTP protocol completion, and URTP by race and covariate measures. Multivariable Cox proportional hazards regression assessed the effect of race on risk of RTL and RTP recovery time points.

RESULTS

SA largely identified as White (75%) followed by Black (14%), multiracial (7%), and Asian (3%). More than half (53%) of all SA reported a household income of >$120,000, whereas 41% of Black SA reported a household income <$60,000. Race was not associated with relative risk of RTL or iRTP but was associated with RTP protocol completion and URTP. Non-Black/non-White SA were 17% less likely (adjusted hazard ratio = 0.83; 95% confidence interval = 0.71, 0.97) to complete the RTP protocol, and Black SA were 17% more likely (adjusted hazard ratio = 1.17; 95% confidence interval = 1.05, 1.31) to reach the URTP time point compared with White SA.

CONCLUSIONS

The present findings suggest collegiate SA enrolled in the Concussion Assessment, Research, and Education Consortium are primarily White and come from household incomes well above the US median. Race was not associated with RTL or iRTP but was associated with RTP protocol duration and total time to URTP. Clinicians should be conscientious of how their implicit or preconceived biases may influence SRC management among National Collegiate Athletic Association SA.

Athletic Trainers' Perceptions of and Experience with Social Determinants of Health

The role that social determinants of health (SDHs) play in athletic healthcare is gaining attention, yet little is known about athletic trainers' (ATs) perceptions of and encounters with the impact of SDHs. The purpose of this study was to evaluate ATs' perceptions of various SDHs and their experience treating patients whose health and well-being were influenced by SDHs. This was a cross-sectional, web-based survey completed by 1694 ATs (completion rate = 92.6%; 61.1% female; age = 36.6 ± 10.8 years). The survey consisted of several multipart questions focusing on specific SDHs. Descriptive statistics were used to report frequencies and percentages. Results indicated widespread agreement that SDHs matter to patient health and are of concern in athletic healthcare. The SDHs that ATs most commonly reported encountering included lifestyle choices (n = 1306/1406; 93.0%), social support (n = 1185/1427; 83.0%), income (n = 1167/1502; 77.7%), and access to quality and timely healthcare (n = 1093/1420, 77.0%). The SDHs that ATs least commonly reported having experience with was governmental policy (n = 684/1411; 48%). The perceived importance of SDHs among ATs and their commonly reported experiences managing patient cases in which SDHs negatively influence patients' health and healthcare suggest that efforts to assess these factors are needed so that strategies to address their influence on athletic healthcare can be identified.

The Integration of Patient-Centered Care and the Biopsychosocial Model by Athletic Trainers in the Secondary School Setting

Our purpose was to explore the degree to which secondary school athletic trainers (SSATs) perceive they are integrating the principles of patient-centered care (PCC) and the biopsychosocial (BPS) model in their practice. We used a cross-sectional design to explore the primary research question. We used the Global Perceptions of Athletic Trainer Patient-Centered Care (GPATPCC) tool and the Biopsychosocial Model of Health (BPSMH) tool, both measured on a 4-point Likert scale (1 = strongly disagree, 2 = disagree, 3 = agree, 4 = strongly agree, with an unscored "unsure" option). We sent the survey to 5665 SSATs through the National Athletic Trainers' Association. Results indicate participants expressed strong agreement (mode = 4) with 7 of the 14 statements and agreement (mode = 3) with the remaining 7 statements of the GPATPCC tool (grand mean = 3.4 ± 0.8). Overall, participants rated their level of agreement on the BPSMH as agreeing (mode = 3) for each item (grand mean = 3.0 ± 1.0). SSATs perceive they are integrating the principles of PCC and the BPS model in clinical practice. These findings align with two previous studies concluding that patients, parents, and providers believe athletic trainers provide care that is focused on whole-person healthcare.

The Role of Title 1 Secondary School Athletic Trainers in the Primary and Patient-Centered Care of Low Socioeconomic Adolescents

Athletic trainers (ATs) provide regular encounters with a healthcare provider for many Title 1 student-athletes with healthcare access and quality barriers. Thus, they are uniquely positioned to serve as a student-athletes' first point of contact for general medical concerns. This study aimed to describe ATs' experiences providing primary care for Title 1 student-athletes. This qualitative design employing an interpretative phenomenological analysis (IPA) approach used in-depth, virtual focus groups to examine the experiences of ATs practicing at Title 1 secondary schools. The findings reveal that ATs were called upon to evaluate, treat, and, when necessary, refer student-athletes with general medical conditions. However, Title 1 ATs encountered numerous complex social determinants of health (SDoH) preventing efficient and effective referral to specialty healthcare providers. Thus, ATs ultimately felt their most important roles in the primary care of low socioeconomic adolescents were as caregivers who mitigated avoidable healthcare barriers in addition to coordinators of integrated care that assisted student-athletes and their families with navigating the healthcare system. Title I ATs need to be aware of the SDoH affecting their student-athletes and the ability of those SDoH to affect health outcomes as well as overall student-athlete health and well-being.

Practices and Perceptions of Family-Centered Care: A Cross-Sectional Survey of Secondary School Athletic Trainers

Family-centered care (FCC) includes collaboration between families and healthcare providers, the creation of flexible policies, and the family taking an active role in the delivery of care. Secondary school athletic trainers provide care for underage patients in school-based health systems, making them responsible for maintaining communication with parents, guardians, and/or caregivers. This cross-sectional survey investigated the extent to which athletic trainers (n = 205) include aspects of FCC in their daily secondary school clinical practice (current practices = CP) and whether they believe that aspect of care is necessary for FCC to be provided in athletic training (perceived necessary = PN) in their everyday practice using the Family-Centered Care Questionnaire-Revised tool. The total mean score for the CP scale (mean = 26.83 ± 4.36) was significantly lower (p ≤ 0.01) than the PN scale (mean = 35.33 ± 4.17). All FCC subscales compared between CP and PN were significantly different (p ≤ 0.01), with each being of higher importance than CP in athletic training. Data analysis revealed four themes related to enhancing FCC in secondary schools: limited education and resources, staffing and space concerns, non-technical skills, and social determinants of health. Attention should be placed on developing resources and interventions for secondary school athletic trainers to collaboratively work with children and their support systems.

Athletic Trainer's Varying Levels of Awareness and Use of Disablement Model Frameworks: A Qualitative Study

In healthcare, disablement model frameworks aim to improve the delivery of patient-centered care through the recognition of patient factors beyond impairments, restrictions, and limitations, which include personal, environmental, and societal factors. Such benefits translate directly to athletic healthcare providing a mechanism for athletic trainers (ATs), as well as other healthcare professionals, to ensure that all aspects of the patient are managed prior to returning to work or sport. The purpose of this study was to investigate ATs recognition and use of disablement frameworks in current clinical practice. We used criterion sampling to identify ATs who were currently practicing from a random sample of ATs that participated in a related cross-sectional survey. A total of 13 participants engaged in an online, audio-only, semi-structured interview that was audio-recorded and transcribed verbatim. A consensual qualitative research (CQR) approach was used to analyze the data. A coding team of three individuals used a multi-phase process to construct a consensus codebook that identified common domains and categories among the participants' responses. Four domains emerged regarding ATs' experiences and recognition of disablement model frameworks. The first three domains were related to the application of disablement model frameworks: (1) patient-centered care, (2) limitations and impairments, and (3) environment and support. Participants described varying degrees of competence and consciousness regarding these domains. The fourth domain related to participants' exposure to disablement model frameworks through formal or informal experiences. Findings suggest that ATs largely demonstrate unconscious incompetence regarding the use of disablement frameworks in clinical practice.

Secondary School Athletic Trainers' Navigation of Patient Socioeconomic Status Challenges in Care: A Qualitative Study

Secondary school ATs (SSATs) are uniquely positioned healthcare providers at an optimal public health intersection where they can provide equitable healthcare to low socioeconomic status (SES) adolescents. SSATs face similar challenges to physicians in treating low SES patients, but their strategies may be different compared to other medical professions. However, the consequences of low SES population healthcare delivery by SSATs have not been explored. SSATs were asked to share what challenges, if any, they encounter with providing care for their low SES patients and what strategies they find most effective to overcome these challenges. Data were collected via semi-structured interviews and reflective field notes and analyzed using a four-step, interpretative phenomenological analysis (IPA) guided theme development. Data saturation was met, and the sample size aligned with other IPA studies. Trustworthiness was established with research triangulation and Yardley's four principles. Three interrelated themes emerged: (a) mechanisms for identifying SES, (b) the impact of SES on care, and (c) navigating SES challenges. SSATs described many strategies that were gained through their clinical experiences to overcome healthcare barriers. SSATs have the potential to decrease health disparities through their role as a liaison and advocates for their low SES patients.

Validation of a Script to Facilitate Social Determinant of Health Conversations with Adolescent Patients

Current social determinants of health (SDOH) tools exist to assess patient exposure; however, healthcare providers for the adolescent population are unsure of how to integrate SDOH knowledge into clinical practice. The purpose of this study was to validate a focused history script designed to facilitate SDOH conversations between clinicians and adolescents through the use of the Delphi method. Six individuals (1 clinician, 5 educators/researchers) participated as expert panelists. Panelists provided critical feedback on the script for rounds 1 and 2. For rounds 3-7, panelists received an electronic questionnaire asking them to indicate agreement on a 6-point Likert scale (1 = strongly disagree, 6 = strongly agree). We defined consensus as mean item agreement ≥ 5.0 and percent agreement ≥ 80%. In round 7, panelists rated overall script level of agreement. After seven rounds of feedback, the focused history script achieved content validity with 100% of panelists agreeing on the final 40-item script. A focused history script for the SDOH was content validated to aid conversations between healthcare providers and adolescent patients on factors that affect their life, school, and play. Addressing social determinants of health with adolescent patients will improve cultural proficiency and family-centered care delivered by school healthcare professionals.

Association of Ankle Sprain Frequency With Body Mass and Self-Reported Function: A Pooled Multisite Analysis

CONTEXT

Ankle sprains result in pain and disability. While factors such as body mass and prior injury contribute to subsequent injury, the association of the number of ankle sprains on body anthropometrics and self-reported function are unclear in this population. Therefore, the purpose of this investigation was to assess differences in anthropometric measurements and self-reported function between the number of ankle sprains utilizing a large, pooled data set.

DESIGN

Cross-sectional.

METHODS

Data were pooled from 14 studies (total N = 412) collected by the Chronic Ankle Instability Outcomes Network. Participants were categorized by the number of self-reported sprains. Anthropometric data and self-reported function were compared between those who reported a single versus >1 ankle sprain as well as among groups of those who had 1, 2, 3, 4, and ≥5 ankle sprains, respectively.

RESULTS

Those who had >1 ankle sprain had higher mass (P = .001, d = 0.33) and body mass index (P = .002, d = 0.32) and lower Foot and Ankle Ability Measure-Activities of Daily Living (P < .001, r = .22), Foot and Ankle Ability Measure-Sport (P < .001, r = .33), and Cumberland Ankle Instability Tool (P < .001, r = .34) scores compared to the single ankle sprain group. Those who had a single ankle sprain weighed less than those who reported ≥5 sprains (P = .008, d = 0.42) and had a lower body mass index than those who reported 2 sprains (P = .031, d = 0.45).

CONCLUSIONS

Some individuals with a history of multiple ankle sprains had higher body mass and self-reported disability compared to those with a single sprain, factors that are likely interrelated. Due to the potential for long-term health concerns associated with ankle sprains, clinicians should incorporate patient education and interventions that promote physical activity, healthy dietary intake, and optimize function as part of comprehensive patient-centered care.