The Athletic Trainer as a Public Health Foot Soldier

Dear Editor,

The American Public Health Association defines “public health” as the practice of preventing disease and promoting good health within groups, from small communities to entire countries where people live, learn, work, and play, combined with injury and illness prevention, and with promotion of wellness through healthy behaviors. ²³ The Centers for Disease Control and Prevention Foundation defines it as “the science of protecting and improving the health of families and communities through healthy lifestyle promotion, research to prevent disease and injury, and early detection and control of infectious diseases using evidence-based translational healthcare”. ¹⁹ While healthcare providers primarily focus on treating individual patients, public health services focus more on entire populations or groups, stressing prevention over treatment, and populations over individuals, with engagement at multiple levels. ³

Health disparities adversely affect groups who have experienced greater healthcare obstacles because of their race or ethnicity; religion; socioeconomic status; gender; age; mental health; cognitive; sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics linked to discrimination or exclusion. ³ Socioeconomic status influences both the healthcare available to each person, and its outcome efficacy. ⁸ Failure to evaluate and completely understand the impact of an individual’s social determinants of health, health literacy, and socioeconomic status decreases the ability of the healthcare professional to provide the care needed to achieve holistic health and wellbeing.^3,16 Approximately 80% of health outcomes are determined by factors beyond medical care; therefore, healthcare professionals need to have a sound understanding of how various health determinants influence overall student-athlete health. ¹³ No matter what one’s opinion is about worldwide public health model sustainability, one certainty is that more effective population or community-based, patient-centered wellness-prevention healthcare is needed, particularly for “at risk” individuals.

Teaching school-based athletic trainers (SB-ATs) how to better evaluate and navigate youth and adolescent athlete social determinants of health and health literacy may reduce healthcare disparities. ³ Although the services provided by the athletic training and public health professions clearly intersect, public health focuses more on improving community health, while athletic training focuses more on translating healthcare to individuals.^9,10 With a stronger background in traditional population or community-based public health approaches in combination with existing patient-centered healthcare, SB-ATs would be more empowered to decrease healthcare disparities and improve treatment outcomes.^9,10 Reducing disparities through prevention is a public health priority in the USA.^22,24 Since SB-ATs are often the first or only contact point for student-athletes to receive healthcare information, they have a unique insight into the individual and community-level exposures that influence health behaviors and outcomes.^3,7 They routinely observe the mental health, substance use, housing and food insecurity concerns that are linked to student-athletes’ health behaviors, social circumstances, and physical environments. ³ With greater emphasis on community-based care coordination, screening and prevention, and social equality in health, SB-ATs should be more involved with community-based policy development, as they act on them daily in providing youth and adolescent athlete healthcare. ²⁴ Although they primarily provide direct healthcare to student-athletes (ie game and practice coverage and injury rehabilitation), greater time is now spent in areas that directly affect public health outcomes (ie social circumstances, individual behaviors, and physical environments).^3,7

The 2020 Professional Athletic Training Program Educational Standards ¹⁸ advanced the composite skills, knowledge and ability expectations for athletic trainers (ATs). From providing expedient emergency care, to the diverse public health issues associated with COVID pandemic navigation,^4,25 there is no question that the AT practice domains (risk reduction, wellness, and health literacy; assessment, evaluation, and diagnosis; critical incident management; therapeutic intervention; and health administration and professional responsibility) ⁵ necessitate proficiency in managing active youth and adolescent athletes with diverse physical, mental, and emotional healthcare needs in a highly adaptive manner. ¹⁴ Although the terms “social determinants of health,” “health literacy,” and “population or community-based healthcare decision-making” may not be new to ATs, knowing how to operationalize them into effective actions often are. ³ Rapidly changing societal demographics have increased the foundational knowledge, skills and abilities required for effective contemporary SB-AT practice.

Too often, AT services are unrecognized, under-staffed, ¹⁷ or under-appreciated.^15,20 From conducting pre-participation physical examinations, to developing emergency action plans, completing electronic injury surveillance records, and requiring athletes to keep the cooler lid on to prevent germ spread, they regularly perform population or community-based healthcare.^9,10 Updated educational standards may provide the needed impetus to better integrate the AT into the contemporary public health education and healthcare model. Aristotle stated that “nature abhors a vacuum”. ¹ To more effectively achieve the public health mission, it would be advantageous for athletic training education programs to partner with schools of public health.

The 2021 Council on Education for Public Health (CEPH) accreditation criteria describes the potential for AT integration into public health schools (Section D). ⁶ These domains include foundations of biological and life sciences, science of human disease, data collection and analytics, process and approach to population interventions, concepts of implementation (planning, assessment, evaluation), USA health system structure, health and policy legal, ethical, economic and regulatory dimensions, health communication, community dynamics, public health promotion advocacy, and many more. Section E of the same criteria describes the potential for ATs to serve as public health faculty potentially serving as preceptors, educators, research partners, and important conduits for front line community engagement to leverage early intervention to better achieve public health goals. ⁶ Whether providing healthcare at sporting events, counseling about nutrition, helping decrease pre-competition anxiety, implementing knee injury prevention neuromuscular training programs, organizing Special Olympic or Paralympic events, discussing post-surgical return to play criteria with a parent, de-briefing the guardian of a seriously injured athlete, or any of a wide breadth of responsibilities, the SB-AT has long relied on elements of public health. A “foot soldier” is one who actively does difficult work for an organization or cause. ²¹ We submit that today’s SB-AT serves as a public health “foot soldier”.

Population or community-based healthcare is grounded in the concept that the professionals who provide services fully understand the causes, conditions, factors, and goals that determine community or group health. Although the SB-AT has the primary responsibility of providing healthcare to student-athletes, to improve the outcome efficacy of their translational healthcare interventions they should be better prepared to identify and manage the effects that social determinants of health and health literacy have on the groups that they serve.^3,8,24 To accomplish this mission, it is imperative that SB-ATs better understand the positive impact they can have on public health.^9,10 Many perceive that they were not adequately prepared to identify and intervene with lower socioeconomic status student-athletes ⁸ and are not familiar with how to develop and evaluate healthcare policies, and implement comprehensive translational clinical practice initiatives using traditional public health approaches.^9,10 Developing improved educational opportunities to better prepare SB-ATs to identify population or community-based healthcare concerns that consider social determinants of health and health literacy is critical.^3,22,24 Concerns facing physically active children and adults such as concussions, heat-related illness, osteoarthritis, sudden cardiac death, and substance abuse require population or community-based interventions. ² We suggest that this vacuum cannot go unfilled. To better assess population health and disability and help healthcare professionals communicate more effectively, in 2001, the World Health Organization’s International Classification of Functioning, Disability and Health (ICF) proposed a “common language” for healthcare professionals. ¹¹ With improved preparation in population or community-based public health practices, development of a better understanding of the influences of social determinants of health, and health literacy on healthcare disparities, and on policy development and evaluation, the AT will be better prepared to implement the ICF model as they fulfill their unique public health “foot soldier” role.^3,9,10,12 For this to happen a paradigm shift must occur where SB-ATs view the groups that they serve from a population or community-based perspective. Therefore, it might be beneficial to integrate the AT with public health education.^9,10 To our understanding, this idea was first described in the athletic training community in 2016, ⁹ and further discussed in 2019. ²² As we approach the mid-way point of 2023 we propose that this process should be accelerated. Consider this a call to action to athletic training education programs, communities and legislators to better partner the AT with the public health infrastructure, possibly with the creation of a new supplemental training certificate title such as an Athletic Public Health Trainer (APHT) or Athletic Health Education Trainer (AHET).

—John Nyland, EdD, ATC, DPT, SCS, CSCS, FACSM
Senior Research Scientist, Norton Orthopedic Institute, Louisville, Kentucky
Clinical Professor, Department of Orthopaedic Surgery, University of Louisville, Kentucky

—Demetra Antimisiaris, PharmD, BCGP, FASCP
Associate Professor, School of Public Health and Information Sciences, University of Louisville, Kentucky

—Alma Mattocks, PhD, ATC
Assistant Professor, Master of Science in Athletic Training Program Director, Spalding University, Louisville, Kentucky

—Ryan Krupp, MD
Sports Health Director, Norton Orthopedic Institute, Louisville, Kentucky
Clinical Professor, Department of Orthopaedic Surgery, University of Louisville, Kentucky