Table 4.

Additional Quotations to Support Themes Continued on Next Page

Theme	Quotation
Catalyst to change	“It was something that our state association had been working towards ever since the NATA [National Athletic Trainers' Association] position statement had come out, but at that time High School Coaches' Association, the arts activities, nobody was willing to do change. They acknowledged it, they saw it, but they saw it as athletic trainers meddling again and so once we had the high-profile incidents where we had 3 kids within 1 week collapse, 2 football players, 1 basketball player … it really made our state look bad. We've had a legislative task force on athletic training in secondary school settings for going on our 10th year, and so we've been already trying to move towards those changes but were meeting opposition from people. But once all that happened in 2011, finally everybody came to the table, and it's like: ‘What do we have to do?'” [Dan]
	“I think, unfortunately, tragedies make people listen. And I think that's what really helped Arkansas get through the changes. You know, would it have been as easy without a tragedy? I don't know because I tried 18 years ago and then I talked to people in between, and I could never get it beyond our local school district.” [Sue]
	“They [the state of Georgia] actually had 2 kids in the summer of 2011, they had 2 kids pass away and 1 was ruled cardiac, but I think it stemmed from heat. So they had 2 kids die, 1 was in Florida in practice. …That's when our study was ongoing. We had a study going on 2 years before that. So the study we had was a 3-year-long study. And that was the final year of the study. So what was happening was the Georgia High School Association was kind of waiting on us to get some data out so they can implement new guidelines based on hard data instead of just kind of throwing out guidelines.” [John]
	“‘They've got 30 high schools around the state with state-of-the-art equipment and they have [athletic] trainers that are taking readings every 15 minutes, starting before practice until after practice, and then they keep up with any heat-related issues that come up during practice,' [representative] said. ‘When that study is over, we'll have hard and fast data that will maybe cause us to change our policy,' he said.”20,21
	“We took a step which we thought was a pretty good step, but we determined that it really wasn't nearly adequate enough, where we said every one of the schools had to establish, had to buy into a heat policy from a recognized national organization. It could be from a national [athletic] trainers' organization, it could be from one of the military branches, or whatever. But we left it up to the local school district to make its own policy with the understanding that the schools in the north Georgia mountains are in a whole different setup than the schools in the swamps of deep-south Georgia. What we found was that it was a little bit inadequate because it gave people some latitude that they were kind of taking advantage of. So then we decided [that] what we really need to do was to determine an actual factual research-based policy.” [Jack]
	“The 1 piece of information that resonated most with the football subcommittee and the full Board of Control was the fact that Georgia had the most heat-related fatalities since 1990. Most of the policy makers had been aware that some fatalities had occurred but had lost track of the actual numbers even though they all agreed that 1 was too many. The research project revealed important, empirical data about a number of variables that were involved in creating danger situations for student-athletes. The Board of Control believed that data and were willing to step forward to make changes.” [Jack]
	“Their [leader, Jack] was very interested in making an evidence-based policy rather than just responding to public opinion. And you know we both came under, he more than I, but there's a lot of pressure from media, particularly in 2010 or '11, when we had a death, and you know the Georgia High School Association stood strong, and said: ‘We're in a 3-year study, we're going to collect the 3 years of data, and then we're going to make policy changes.'” [Ed]
	“We didn't have anything documented. But I can tell you that I received [tele]phone calls from people saying that you know listen we had [to] send a kid to the ER [emergency room] today and it was things like that were really just never documented but we knew that problems were out there.” [Andrew]
	“I also sat on that committee with [Andrew, our other participant from New Jersey who was a high school athletic trainer and served on the Sports Medicine Advisory Committee], and they just wanted to be proactive about it, let's get it out there, let's keep the kids protected, that's the job of our medical advisory committee.” [Lauren]
	“We spoke to quite a few attorneys from across the country and they all said the same thing, which is, now that there are national guidelines, if an athlete goes down with a catastrophic injury, we're going to approach 2 people. One is the state association, and we're going to say: ‘There are national guidelines out there, why didn't you follow them? You're going to be held accountable.' And the second group we're going [to] approach is the school district, with the same question. So what I told my state association was: ‘Listen, if you pass these guidelines, it washes your hands liability-wise because you're doing what you should do. Now it's up to the school district.' And all the administrators looked at each other, and they said: ‘You know what, you're right. We don't need this problem.'” [Andrew]
	“All of our coaches, that's a common theme when you get coaches together, they had this haunting fear that they were going to lose a kid in August. That's what you hear a lot, and so I think before we even did this policy, our coaches were more aware than ever before about the problems that were involved.” [Jack]
Policy selection	“We started with the National Athletic Trainers' Association [consensus] statement on [preseason heat-acclimatization guidelines for secondary school athletics]4 … and the National Collegiate Athletic Association policy, and we started … with that as our baseline, and then we worked to find some good areas [to start with].” [Ed]
	“We had, pretty early on had, of course, looked through research and had found that the Korey Stringer Institute was the … leader in this field, so we … went through and looked at their recommendations and research, and that's what we based it of off.” [Lenny]
	“Whenever there were questions with the [state organization] they could always fall on, well we got this from the National Athletic Trainers' Association, it's a national guideline. It's not something that we just developed in the back room of our own little association.” [Andrew]
Change process	“Coaches are coaches, and … they don't want to be told what to do … They are ‘football coaches and nobody tells them what to do' and ‘we do what we do' and you know even the coaches … were pro–athletic trainer and things like that. … You know they would come in and say: ‘You know yes, I'm going listen to my athletic trainer, and I'm going to do what they, you know, advise me to do. But I do not want a policy that handcuffs me in what I can and can't do.' … They kept seeing it as if they were going to be handcuffed [being told] how they could run their practices, when they could have their practices, you know stuff like that.” [Dan]
	“It has to be a team approach for a statewide implementation. Even if you are trying to make changes just within your school, clinic, our [or] wherever you are employed, it is best to have individuals that can help you. Just having other opinions, thoughts, [and] ways of doing things, helps you see answers to obstacles that as an individual you might not see. Sometimes you cannot see the trees for the forest in front of you.” [Dan]
	“You have to get the leaders in those areas together. People that can make a decision and people that can get the message to their people or to their entity about the importance of the matter and why we have to do it this way in a practical manner.” [Lenny]
	“We'd put committees together to look at this research, and you know of course with people having schools and schedules and people all over the state, we had to do this over like a 5-, 6-month period. … And that was, you know where we kind of got everybody on board, all the different groups that are affected within the schools, and provided research and talked about how we can make this work the best, most practical way. That's one of the things you forget about, is that piece of it, whenever we had the different committees of coaches, officials, principals, superintendents, parents, groups coming in to get their buy-in.” [Lenny]
	“I really feel like that maybe compared to some other states that are looking at this, we tried to balance the sports concerns and medical concerns … so what we tried to do was something [that] was medically sound and at the same time was athletically practical, and I think that's what we've been able to come up with.” [Jack]
	“No one ever likes to be ‘told' what to do. I've found that it's much easier to get what you want by being a teacher presenting facts, listening to the concerns of your audience then spinning it by having the audience believe it's their idea.” [Andrew]
	“We took our football subcommittee off our Board of Control over to the University of Georgia to see the results of the study … so we had administrators and coaches and athletic directors all involved and going out there and hearing this.” [Jack]
	“There is no resistance, just logistics. Like I said, you know we wanted to hit the main groups, the schools, coaches, parents, students, and medical personnel, just logistics of trying to work through and get in touch with. You know the proper folks in the medical field help us broadcast our message and our concerns.” [Lenny]