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Extremity and Joint Conditions/Special Communications

Disparities and Inequities in Youth Sports

Kuhn, Andrew W. MD1; Grusky, Alan Z. BS2; Cash, Carsen R. BS2; Churchwell, Andre L. MD2; Diamond, Alex B. DO, MPH, FAAP, FAMSSM3

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Current Sports Medicine Reports: September 2021 - Volume 20 - Issue 9 - p 494-498
doi: 10.1249/JSR.0000000000000881
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Abstract

Introduction

Nearly three quarters of all children ages 6 to 12 years in the United States play team or individual sports at least once a year and over a third engage in team sports on a regular basis (1). The benefits of youth sports and regular physical activity for children are numerous and include the following: increased cardiorespiratory and musculoskeletal health; decreased risk of childhood obesity; increased academic achievement; and opportunities for important psychosocial development (2–6). Unfortunately, some youth populations are unable to participate and/or reap the benefits of sports because of existing inequities. This article provides a review of the numerous disparities and inequities in youth sports. Compiling and understanding these data may help in developing a framework to make youth sports more equitable and beneficial for all.

Disparities in Youth Sport Participation Rates

U.S. children who come from household incomes greater than $100,000 participate in sports at almost twice the rate as those from households with incomes less than $25,000 (42.7% vs 21.6%) (1). Recent Dutch, Flemish, and Finnish studies also have reported that household income is positively associated with the likelihood of playing sports for children (7–9), a global disparity that has been slowly growing over time (10). Alongside those coming from lower socioeconomic status (SES), ethnic minority children (specifically African American/Black and Hispanic children) also have been found less likely to participate in sports when compared with Caucasian/White, non-Hispanic children (1,7). This trend extends into adolescence, where White girls and boys in high school participate in team sports more often than other racial and ethnic minority groups (11). These disparities in youth sport participation are unfortunately pervasive and may be the result of multiple barriers including financial and time constraints, limited resources and the inability to access facilities both in and out of school, and lack of familial support (1,12–14).

Barriers to Youth Sports Participation

Affordability

Perhaps one of the most obvious barriers to participating in youth sports are the financial demands, because cost has been one of the most commonly reported constraints to youth sports participation (15). Parents of youth and adolescent athletes report spending a median of just over a thousand dollars per year on their children's sporting activities (16), an expense that many simply cannot afford. Unfortunately, as sport fees continue to rise, youth athletes have had to learn that “if you cannot pay, you cannot play” (13). Importantly, even if parents are able to afford entry or registration fees, they may not be able to invest more into their children's sporting activities. Children from higher SES have been shown to play organized sports more hours per week, train more months per year, and become more highly specialized in their main sport than those from lower SES (17). Parents from higher SES have been shown to spend more to have their child specialize in a single sport, paying as much as $3000 per year (18). Although the issue of specialization has its own concerns (19,20), these data reveal the inequities that exist regarding the ability to invest in a child's athletic development and future.

Time Constraints

In addition to financial constraints, time also is a barrier for some youth and their families. For middle schoolers, time has been listed as a common obstacle to sports participation (12). Lack of time also is responsible for causing physical activity rates, including sport participation, to drop as children and adolescents grow older (21). “Time constraint,” however, is not well defined, has many meanings, and varies across both cultures and by individuals (22); for instance, while two individuals may have equal time commitments, one may view time constraints as more pressing than another (12). For lower SES children, lack of resources and the ability to access facilities has been reported as a more salient barrier than time constraints (12).

School Resources and Accessibility to Facilities

The lack of available resources, facilities, and opportunities at low-income schools restricts sports participation for those attending. In a large study of more than 54,000 U.S. students, those from lower SES attended schools with the lowest rates of varsity sports participation. The authors hypothesized that most sports require appropriate facilities, personnel, equipment, parental involvement, and travel, all of which may be more affordable to families of higher SES and schools with a higher tax base (23). As has been shown in other studies, low-income schools are more likely to only have a single gym, offer less intramural activities, and have fewer exterior athletic facilities (24). Beyond athletics, children attending low-SES schools also have been found to have less access to physical education teachers and less physical education, in general, than high SES schools (25).

Neighborhood, environment, and accessibility to other nonschool facilities also may be associated with disparities in youth sport participation. The “built environment” takes into account numerous characteristics of neighborhoods, including walkability, distance to sporting facilities (26), and other considerations such as safety. In an Australian study that examined the geographical association between the availability of sport facilities and participation across an entire Australian state, participation rate was positively associated with the availability of such facilities. This was modified by SES and region, where nonurban areas generally had higher participation rates and better access to facilities than urban regions (27). Similarly, a study from Spain surveyed adolescents aged 14 to 18 years and found that there was a neighborhood SES main effect for participation in sports/PA classes, with adolescents living in higher-SES areas participating in more sports teams/PA classes than those living in lower-SES neighborhoods (28).

Familial Support

Familial support, or lack thereof, also is an important factor in youth sport participation. In an Australian study that examined predictors of sports participation as a function of SES, low SES girls reported lower levels of both instrumental and affective support from parents to play sports (29). Parents who do not prioritize physical activity or sports themselves may inadvertently influence their own children's views, as one study found that the father's own physical activity (both past and present) influences sports participation patterns in children (30). Children from low SES are more likely to be in nontraditional family households (31), and this also may influence their sports participation. As shown in a study of Canadian youth, children from reconstituted families and single-parent families with regular visitation of a second parent are less likely to participate in organized sport than those from traditional families (32).

The Benefits of Youth Sports

Participation in youth sports can have a positive, lasting impact on a child's general health and physical well-being. In younger children, organized sport has been shown to support physical literacy [defined as “the motivation, confidence, physical competence, knowledge, and understanding to value and take responsibility for engagement in physical activities for life (33)], which may enable children to engage in habitual physical activity and reduce their sedentary time (34,35). For older children and adolescents, sport participation can lead to greater enjoyment of physical education, becoming more physically active on a daily basis, and performing better on fitness tests (including pull-ups, grip strength, and the plank test) (36). At the physiological level, data also suggest a positive association between sports and physical health in youth. In a study of middle school girls, those who played team sports had improved musculoskeletal health compared with those who did not, as measured by ultrasound and bone mineral density (37).

The benefits of youth sports, however, are not limited to just physical ones. Sport also has been shown to provide youth with psychological and psychosocial benefits, including structure and stability (38). In addition, important lifelong lessons and traits that are needed for success beyond the playing field are developed, such as resilience (39). In large studies of middle and high school athletes, including those who have experienced childhood adverse events, those who played team sports reported lower odds of depression and anxiety, as well as current depressive symptoms compared with individual sport athletes and nonathletes (40,41). High school athletes who play team sports also have demonstrated lower odds of emotional distress, suicidal thoughts, attempted suicide, and were shown to have improved self-image (42). Importantly, those engaged in sports may be more likely to avoid harmful behaviors or habits, such as smoking, alcohol consumption, illicit drug use, fighting, vandalism, and so on (42). Lastly, youth who participate in sports may demonstrate improved academic performance (43).

Inequities in Benefits Received from Youth Sports

Inner-city parents and children likewise view sports as an avenue for “developing health habits” and “becoming physically fit and healthy” (44). Sports can have profound, perhaps even life-changing effects for those who paradoxically face the greatest barriers to participation. For socially vulnerable youth, sports participation can be associated with prosocial behavior, subjective health, well-being, and a sense of coherence (45). Also, data from the American High School and Beyond Study demonstrated that for minority high school youth, sports participation can be correlated with popularity, involvement in extracurricular activities, and in some areas, lower drop-out rates (46).

However, certain populations may internalize sports participation differently, creating an inequity in benefits rendered. Stereotypes can form an early basis of racial identity in youth, and some minority children may feel more welcomed in certain sports than others. The phenomenon of athletes from one's own racial background having achieved significant athletic success may put pressure on young athletes to similarly excel (14). For instance, African Americans may feel more welcome in basketball and football, but not in other sports (14). In a study of division IA football athletes, African Americans had a stronger athletic identity compared with their Caucasian counterparts. Specifically, they were more internally focused on their sport, felt that others perceived them only as athletes, and saw sport as the focal point in their lives (47). In a nationally representative sample of 3rd through 12th graders, African American youth were more likely to receive encouragement for sports participation from all sources (families, nonkin, teachers, coaches, and peers) (48). Also, in a study of urban high school athletes (67% Black, 27% Hispanic, 10% “other”), many believed unrealistically that they would “definitely” or “probably” receive an athletic scholarship (49). Data from the Centers for Disease Control and Prevention indicate that among Caucasian students, sport participation was related to multiple positive health behaviors. Conversely, for African American, Hispanic, and other minority student athletes, fewer positive health behaviors and even some negative behaviors were associated (50), again highlighting how sport involvement may be internalized differently among a subset of youth populations.

Inequities in Access to Care and Outcomes from Sports Injuries

Some youth populations also bear a greater burden of sport-related injury due to lack of surveillance, education, and participation in noncontact or less-contact based sports. Licensed athletic trainers (ATCs) play an important role in decreasing injury burden in youth sports. ATCs are essential not only for treating and evaluating overt injuries in young athletes, but also for recognizing and diagnosing injuries, such as sport-related concussion (SRC), which may have a less obvious presentation. One study of public high schools in Washington state found that football and boys' soccer teams with an ATC had a significantly greater number of diagnosed SRCs compared with teams at schools without an ATC (51). Unfortunately, there are clear SES disparities in access to ATCs, particularly impacting lower resource communities. Schools in urban settings (51), schools with a higher proportion of students eligible for free or reduced-cost lunch (51,52), and schools within lower median household income counties are less likely to have access to the services of an ATC (52).

Differences in education also may contribute to an imbalance in injury risk. These gaps are present at the level of the athlete, coach, and parent. Wallace et al. (53) found that White/Caucasian athletes had more knowledge of SRC than African-American/Black athletes, although the presence of an ATC partially decreased this gap. One study found that youth athletes from lower-income families and youth athletes that live in metropolitan communities are significantly less likely to receive concussion education (54). Kroshus et al. (55) reported that the implementation of the “Heads Up Football” program, an educational initiative aimed at coaches to help address safety concerns in youth football, was less likely to have been adopted by leagues in communities with children living below the poverty line and among communities with a lower percentage of non-Hispanic, White residents. In addition, there is evidence to suggest that preparticipation disparities in parental education level are associated with injury risk in youth soccer (56).

Some populations may not have access to noncontact or lower-contact alternatives that may have less injury risk. In a study of community organizations offering both youth tackle football and flag football in Georgia and Washington, results showed that youth living in communities with lower educational attainment were less likely to have access to the option of a lower contact alternative to tackle football (57).

With regard to treatment of injuries, parents from higher SES households are more likely to be informed and seek care for SRC than those from lower SES, suggesting that parents from lower SES may lack the knowledge and ability to recognize concussion symptoms and adhere to return-to-play protocols and procedures (58). Lastly, there exist inequities with regard to delivery of care. A recent study of youth who sustained an SRC over the last decade found that racial minorities were more likely to leave the emergency department before being seen (59). Also, Hispanic youth, individuals with low English proficiency, and those with nonprivate insurance are less likely to receive subspecialty concussion care (60).

Next Steps

Considerable efforts have been made to try and eliminate inequities in youth sports by targeting the barriers addressed in this review, including the cost of participation, building sport facilities at more nearby locations, providing greater access to these facilities, and determining the suitability of sport-based recreation (61,62). Developing partnerships and leveraging local resources are essential for overcoming these barriers (63). For instance, relationships between academic and community partners that involve shared goals and complementary skills/expertise are paramount (64). Academically, implementing more opportunities and funding for intramural sports may reduce disparities in access to school sports while increasing overall physical activity levels among all children (65,66). Similarly, afterschool sport programs can cultivate positive youth development by promoting positive relationships and providing opportunities for self-exploration in a safe and trusting environment (67). Rigorous needs assessments need to be undertaken alongside local government to enact future sports and recreation planning by cities and its community partners, as demonstrated by the “Play Across Boston” initiative (68). City and neighborhood services play an important role and should be taken into consideration when developing youth programs (69). Lastly, there also is a need for more community based sport programs that incorporate the social underpinnings of children's life situations and create a safe space for youth to see positive alternatives (70). Coaches and mentors serve a vital role for youth athletes in terms of fostering motivation toward health behavior changes in vulnerable youth (71). Lastly, in addition to eliminating disparities in health care delivery, a greater effort should be made to equip all schools with ATCs to increase injury education, surveillance, and management.

Sports medicine physicians and providers can play a specific and pivotal role in helping to eliminate these disparities and inequities in youth sports. On a “day-to-day” basis, we can better address social determinants of health when caring for patients — such as economic stability, neighborhood and physical environment, education, food, community and social context, and the health care system itself. For instance, for patients and parents who may not have extensive knowledge about SRC, or for children whose school does not provide an ATC, we can make a more concerted effort of educating these patients and their families about the signs and symptoms of SRC and other injuries.

On a more “global scale,” an effective health care provider has an intimate knowledge of their community needs, extensive awareness of community resources, and are considered leaders among their peers. We should continue to work to be advocates for those who are marginalized in our own communities by actively supporting policy and organizations that promote justice. Beyond policy itself, we can engage in community service or volunteer our time, money, and/or other material resources toward groups or organizations that similarly help try and eliminate these disparities and inequities.

Conclusions

The benefits of sport can be impactful and even life-changing for youth. This article highlights the disparities and inequities that currently exist in youth athletics. Compiling and understanding these data may help in developing a framework to make youth sports more equitable and beneficial for all. As sports and exercise medicine professionals, we must reach beyond mere understanding and confront the uncomfortable truths of prejudice and systemic bias that negatively affect some youth athletes. We must challenge the status quo in bringing about change. Substantive action will require financial commitments, political advocacy, and multidisciplinary collaboration, which include the private and public sectors, health care, sports organizations, business, government, and community service groups.

The authors declare no conflict of interest and do not have any financial disclosures.

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