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Disparities in Athletic Trainer Staffing in Secondary School Sport

Implications for Concussion Identification

Kroshus, Emily ScD, MPH*,†; Rivara, Frederick P. MD, MPH*,†,‡; Whitlock, Kathryn B. MS*,†,‡; Herring, Stanley A. MD§; Chrisman, Sara P. D. MD, MPH*,†,‡

Clinical Journal of Sport Medicine: November 2017 - Volume 27 - Issue 6 - p 542–547
doi: 10.1097/JSM.0000000000000409
Original Research

Objective: First, to assess whether teams at schools with an athletic trainer (AT) on staff had a higher number of diagnosed concussions than teams without medical personnel present. Second, to assess whether the variability in employment of a certified AT by Washington state high schools is patterned by socioeconomic and demographic characteristics.

Design: Cross-sectional survey.

Setting: Washington state public high schools.

Participants: Stratified random sample of football and soccer coaches (n = 270 teams, 144 schools).

Independent Variables: Presence of an AT and school characteristics (percentage of students qualifying for free or reduced price lunch, rural location, enrollment).

Results: Football and boys' soccer teams at schools with an AT had a significantly greater number of athletes with diagnosed concussions compared to teams at schools without an AT (P < 0.05). There was no difference in number of athletes with diagnosed concussions by AT staffing for girls' soccer. Schools with an AT on staff were significantly more likely than schools without an AT to be in an urban location (P < 0.001), to have an enrollment of 1000 students or more (P < 0.001), and to have a smaller proportion of students eligible for school lunch (P = 0.005).

Conclusions: The present study provides empirical support for the benefit of ATs in diagnosing concussions in high school sport and underscores the challenges to AT staffing in lower resource settings. These findings cause us to critically reflect on the threshold for medical oversight in contact and collision sport from the perspective of risk prevention, and the extent to which disparities in this medical oversight are acceptable in the public school setting.

Clinical Relevance: Strategies for increasing AT staffing in high school sports settings should be explored given their demonstrated benefit in diagnosing concussions.

*Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, WA;

Department of Pediatrics, University of Washington, Seattle, WA;

Harborview Injury Prevention and Research Center, Seattle, WA; and

§Department of Rehabilitation Medicine, University of Washington, Seattle, WA.

Corresponding Author: Emily Kroshus, ScD, MPH, Department of Pediatrics, Univeristy of Washington; Center for Child Health Behavior and Development, Seattle Children's Research Institute, 2001 8th Ave, Suite 400, Seattle, WA 98121 (

Data used in this study were funded by the Robert Wood Johnson Foundation, Public Health Law Research (PHLR) program.

The authors report no conflicts of interest.

Received May 03, 2016

Accepted October 31, 2016

Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.