WIS 200% LIBRARY Michigan State University - n'1— _ This is to certify that the thesis entitled ASSESSMENT OF CERTIFIED ATHLETIC TRAINERS' LEVELS OF CULTURAL COMPETENCE IN THE DELIVERY OF HEALTH CARE presented by Jeremy Marra has been accepted towards fulfillment of the requirements for the Master of Science degree in Kinesiology fléfl/flb Cgl/iLW/VQ‘ Major/Professor’s Signature AW/z/ a? 5,, 2a? Date MSU is an afiinnative-action, equal-opportunity employer --.--u-v—-o— PLACE IN RETURN BOX to remove this checkout from your record. TO AVOID FINES return on or before date due. MAY BE RECALLED with earlier due date if requested. DATE DUE DATE DUE DATE DUE “ JUI: VII-.1370” 5/08 K lProj/Accspres/CIRC/DateDue indd ASSESSMENT OF CERTIFIED ATHLETIC TRAINERS’ LEVELS OF CULTURAL COMPETENCE IN THE DELIVERY OF HEALTH CARE By Jeremy Marra A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of MASTER OF SCIENCE Department of Kinesiology 2008 ABSTRACT ASSESSMENT OF CERTIFIED ATHLETIC TRAINERS’ LEVELS OF CULTURAL COMPETENCE IN THE DELIVERY OF HEALTH CARE By Jeremy Marra Purpose: The purpose of this study was to assess the cultural competence levels of certified athletic trainers (ATCs) in their delivery of health care services. This study also examined the relationship between cultural competence and gender, race, years of experience, and National Athletic Trainers’ Association (NATA) district. Methods: The Cultural Competence Assessment (CCA) and its two subscales, the Cultural Awareness and Sensitivity (CAS) and Cultural Competence Behavior (CCB), were distributed to 13,568 student certified, international certified, and regular ATCs nationwide. All participants were members of the National Athletic Trainers’ Association. Results: ATCs (n=3,102) were found to be moderately culturally competent. Results revealed gender (p=.000) and race (p=.000) were found to be significant indicators of cultural competency levels. However, there were no significant differences on years of experience (p=.093) and NATA district (p=. 141) and cultural competence levels. Conclusion: The current findings provide a baseline for level of cultural competence among ATCs. Educators and employers can use this information to help develop diversity training education for ATCs and athletic training students. ATCs can utilize knowledge to provide culturally competent care to athletes and patients and promote a more holistic approach to sports medicine. ACKNOWLEDGEMENTS To all of you that have helped me achieve academic and professional success over the past six years, I sincerely thank you. If it was not for the support of these individuals, my achievements may not have been fulfilled. First and foremost, thank you to my parents, Joe and Cindy, for providing support in all of the risks and decisions I have made. Your leadership skills and ambition have taught me how to be an efficient, productive young professional. The financial assistance has also been a plus. To my committee, Dr. Tracey Covassin, Dr. René Shingles, Dr. Renee Canady, and Dr. Tom Mackowiac, I am greatly appreciative of your guidance throughout the thesis development process. Tracey, the time and revisions you put into this project were immensely helpful and I could not have done the statistics without your assistance. Rene, your mentorship over the years has molded me into a competent, skilled student, future leader, and athletic trainer. The strives you have made for our profession inspire me to follow in your footsteps. Dr. C, I thank you for bringing a non-athletic training perspective to this research and your invaluable knowledge of the content area. Torn, your applied outlooks helped me develop this research into a more applicable model for athletic trainers. To all of you, I thank you. A special thank you to the Ethnic Diversity Advisory Committee for assisting the funding of this research, especially Veronica Ampey and Dr. Paul Alvarez. Lastly, thank you to all of the certified athletic trainers who responded to this survey. Your efforts can only help further the develop of our profession. iii TABLE OF CONTENTS LIST OF TABLES ................................................................................... vi LIST OF FIGURES ................................................................................. vii CHAPTER 1 INTRODUCTION] Overview of the Problem .................................................................. 1 Significance of the Problem ................................................................ 2 Purpose Statement ........................................................................... 5 Hypotheses .................................................................................... 5 Definition of Terms .......................................................................... 5 CHAPTER 2 REVIEW OF LITERATURE ....................................................................... 7 History of Athletic Training ................................................................ 8 History of Ethnic Minorities in Athletic Training ..................................... 10 History and Evolution of Athletic Training Education and Curriculum ............ 12 Culturally Competent Care ............................................................... 18 Assessment Tools ........................................................................... 20 CHAPTER 3 METHODS .......................................................................................... 24 Research Design ............................................................................ 24 Sample ....................................................................................... 24 Instrumentation ............................................................................. 25 Cultural Competence Assessment Inventory ................................... 25 Psychometric Properties of CCA ............................................... 26 Data Collection Procedures ................................................................ 26 Testing Schedule ............................................................................ 27 Data Management .......................................................................... 27 Data Analysis ................................................................................ 27 Threats to Internal Validity ................................................................ 28 Threats to External Validity ............................................................... 29 CHAPTER 4 RESULTS ............................................................................................ 3O Demographic Information ................................................................. 30 Cultural Competence Assessment ........................................................ 39 CHAPTER 5 DISCUSSION ....................................................................................... 43 Key Findings ................................................................................ 43 Limitations .................................................................................. 46 iv Future Research Considerations ......................................................... 48 Conclusion .................................................................................. 50 APPENDICES ....................................................................................... 52 A. National Athletic Trainers’ Association District Organization .................. 52 B. Recruitment Letter ..................................................................... 55 C. Cultural Competency Assessment (CCA) Inventory with Demographic Information ......................................................................... 57 REFERENCES ...................................................................................... 68 Table 4-2 4-3 4-5 4-6 4-8 4-9 4-10 4-11 4-12 LIST OF TABLES Demographics by Race and Gender ...................................................... 31 Demographics by District and Race and Gender ....................................... 32 Demographics by Employment Setting and Race and Gender ....................... 35 Demographics by Racial/Ethnic Group and Special Population Treated ........... 38 Means and Standard Deviation for Certified Athletic Trainers Total CCA Scores by Gender ........................................................................... 39 Univariate Analysis of Variance by Gender ............................................ 39 Means and Standard Deviation for Certified Athletic Trainers Total CCA Scores by Race .............................................................................. 4O Univariate Analysis of Variance by Race ............................................... 41 Means and Standard Deviation for Certified Athletic Trainers Total CCA Scores by Years of Experience ........................................................... 41 Univariate Analysis of Variance by Years of Experience ............................ 41 Means and Standard Deviation for Certified Athletic Trainers Total CCA Scores by District ........................................................................... 42 Univariate Analysis of Variance by District ............................................ 42 vi LIST OF FIGURES Figure 1 National Athletic Trainers’ Association District Organization ...................... 54 vii CHAPTER 1 INTRODUCTION AND PURPOSE Overview of the Problem The concept of culture and its relationship to athletic training beliefs and practices is virtually unexplored. The continually changing demographics of our growing multicultural population and the injuries and illnesses of people from diverse backgrounds have challenged health care professionals to consider cultural diversity when providing care. More than ever, culturally and ethnically diverse people are immigrating to the United States, and there is a growth of minorities being born. The United States Census Bureau projects the number of minorities to increase from 30.6% in 2000 to 34.9% in 2010, eventually leveling out over the next 40 years (US. Census Bureau, 2004). Based on a National Collegiate Athletic Association’s (NCAA) Race and Ethnicity Self-Study, the number of minority athletes at Division I for men and women has increased fi'om 31.5% in 1999-2000 to almost 34% in 2004-2005 (NCAA, 2006). However, these numbers are not representative of the National Athletic Training Association’s (NATA) certified membership, which currently is comprised of 86.6% white, 2% black, 3% Hispanic, 0.4% American Indian/Alaskan Native, 3% Asian, 1% Other, and 4% Unspecified (NATA, 2007). Some certified athletic trainers (ATCs) may not be aware of cultural differences between themselves and their athletes and patients, unknowingly creating a setting that is uncomfortable to individuals that are of different race and ethnicity. These clinicians must possess the ability to make an accurate diagnosis for patients of a culture other than their own. The profession of athletic training needs to take steps towards professional enhancement by taking cultural issues into consideration when delivering care to diverse populations. Significance of Problem As the field of athletic training grows with over 360 Commission on Accreditation of Athletic Training Education (CAATE, 2008) accredited entry-level athletic training education programs and over 30,000 ATCs nationwide (N ATA, 2008), so must our knowledge of culturally diverse healthcare delivery. This requires understanding of cultural groups’ attitudes, beliefs, and values as they relate to healthcare in order to develop care plans that include cultural diversity. The NATA 4th Edition Educational Competency Matrix defines the common set of skills that entry-level athletic trainers should possess and the structure of clinical education. From this set of competencies, entry-level athletic trainers must possess the knowledge to describe and apply theories and techniques of interpersonal and cross-cultural communication among athletic trainers, their patients, and others involved in the health care of the patient (N ATA Education Council, 2007). The NATA Foundational Behaviors of Professional Practice calls for cultural competence to permeate every aspect of professional practice of athletic trainers. Multicultural intelligence, social experience, and cultural competence is needed to meet this competency, however, these have never been formally assessed through research in the field of athletic training. In 1986, the NATA developed the Minority Athletic Trainers’ Committee to serve as the voice for minority athletic trainers and promote diversity in the sports medicine field. After drastic changes over the past two decades, this committee is now known as the Ethnic Diversity Advisory Committee (EDAC) which identifies and addresses issues relevant to ethnic minority members and health care concerns affecting diverse patient populations. One of the first published works on athletic training diversity occurred in 2000 when Perrin released an editorial on the need for promoting diversity in the field of athletic training (Perrin, 2000). In 2003, Geisler assessed the benefits of including multicultural education, awareness, and training into athletic training education programs. Around the same time, Ford (2003) also released an awareness editorial on working toward cultural competence in athletic training, outlining key points essential to the progression toward competent care. There are only three published works on cultural diversity or cultural care that focus on athletic trainers. Because issues in cultural diversity have not been publicized in this field, cultural competency has not been assessed among ATCs. For this reason, it is imperative to determine if athletic training as a health care profession is considered culturally competent. As a profession, athletic training encourages cooperation and teamwork, and therefore competent interactions with other allied health care providers, physicians, coaches, administrations and students are essential (Peer & McClendon, 2002). Because of the largely diverse population athletic trainers serve and work with, those involved within the profession should possess a certain level of cultural competence. Therefore, this research will provide a baseline level of cultural competency among ATCs. Other health care professions, such as nursing and social work, have used various assessment tools to assess culturally competent care. The scholars of nursing have pioneered research in diverse health care compared to all other professions, including a focus on interpersonal aspects of health care that may contribute to cultural issues that arise. Through their extensive research, these scholars have identified common racial and ethnic disparities and developed interventions for practitioners to utilize to improve patient care (Johnson, Saha, Arbelaez, Beach, & Cooper, 2004; Cooper, Hill, & Powe, 2002). Others have even developed conceptual models to guide healthcare practitioners in achieving higher levels of cultural competence, such as the Pumell Model of Cultural Competence (Purnell, 2002). To achieve this data for the field of athletic training, the Cultural Competency Assessment (CCA) Inventory (Schim, Doorenbos, Miller, & Benkert, 2003) was distributed among eligible participants throughout the nation. This inventory has been used to assess cultural health care competence and knowledge among a variety of health care professionals, but never used to assess ATCs. The CCA uses four basic constructs to assess levels of cultural competency among health care providers: cultural awareness, competence, diversity, and sensitivity. The inventory is designed to reflect nonlinear and interconnection of these four constructs to lead to culturally congruent care. A high score on the assessment would indicate the ATC is culturally aware and sensitive, and demonstrates behaviors of being culturally competent. The results obtained from this research will allow the profession of athletic training to assess competence of cultural care and delivery and possibly mold athletic training programs to include culturally competent healthcare education. As athletic trainers become more culturally competent in their delivery of health care services, there is a potential for greater patient satisfaction and increased continuity between ATCs and other diverse healthcare professionals and patients. As a result of the increasing diversity among the athletes and patients of ATCs, the evaluation of culturally competent service is imperative to the profession of athletic training. Purpose Statement The purpose of this study was to assess the level of cultural competence in health care delivery from ATCs. This study also examined the relationship between cultural competence and gender, race, years of experience, and NATA district. Hypotheses This study examined the following hypotheses: 1. ATCs are culturally competent within their delivery of health care services. 2. There is no difference in the level of cultural competence between male and female ATCs. 3. Minority ATCs will experience higher levels of cultural competence than majority (White/Caucasian) ATCs. 4. There is no difference in the level of cultural competence between newly certified (0-5 years) and experienced (>5years) ATCs. 5. There is no difference in the level of cultural competence of ATCs by NATA district. Definition of Terms Board of Certification (BOC): national certifying body for athletic trainers in the United States; administers ATC® credential to those meeting qualifications to become a certified athletic trainer. Certified Athletic Trainer (ATC): a unique health care provider who specializes in the prevention, assessment, treatment, and rehabilitation of injuries and illnesses. Cultural Compgtence: providing effective services to people of all cultures, races, ethnic backgrounds and religions in a manner that respects the worth of the individual and preserves their dignity; developmental process that evolves over an extended period in which both individuals and organizations are at various levels of awareness, knowledge, and skills on the cultural competence continuum (University of Michigan Health Systems, 2008). Cultural Comfitency Assessment (CCA) Inventory: Inventory used to determine cultural diversity among various health care providers by assessing cultural awareness, cultural sensitivity, and cultural competence. (Schim, Doorenbos, Miller, & Benkert, 2003). Diversity: variety in group presence and interactions, including, but not limited to, age, color, ethnicity, gender, religion, disability, socio-economic status, sexual orientation, gender identity, and national origin (University of Toledo, 2007). Ethnic Diversigg Advisog Committee (EDAC ): a National Athletic Trainers’ Association committee developed to identify and address issues relevant to minorities within athletic training and the healthcare field, advocating sensitivity and understanding towards ethnic and cultural diversity. Ethnicity: social groups with a shared history, sense of identity, geographical and cultural roots which may occur despite racial differences or similarities (Smedley, Stith, & Nelson, 2003). National Athletic Trainers’ Association (NATA): the professional membership association for certified athletic trainers and others who support the athletic training profession. Rage: a group of persons considered distinct based of physical characteristics, usually related by a common social construct (Smedley, Stith, & Nelson, 2003). CHAPTER 2 REVIEW OF LITERATURE Diversity means being accepting of people who are different from oneself or more inclusive and accepting of students, athletes, or colleagues regardless of color, national origin, race, religion, sex, or sexual orientation (Pertin, 2000). To be culturally competent means to understand and integrate these differences and incorporate them into daily care and to work effectively in cross-cultural situations, also known as transcultural health (Cross, Bazron, Dennis, & Isaacs, 1989). The demand for culturally competent health care developed out of the failure of medical services to be responsive to all segments of the population, especially with language and cultural barriers of non-English speaking immigrants and racial and economic barriers faced by people of color (Chin, 2000). Because of past disparities, the profession of athletic training must develop a culturally competent system built on awareness of the integration and interaction of health beliefs and behaviors, disease and injury prevalence and incidence, and treatment outcomes for diverse patient populations. To develop a culture competent system, educators must seek out, understand, embrace, and effectively implement multicultural perspective into athletic training education (Geisler, 2003). However, prior to implementing cultural diversity training, the level of cultural competence must first be assessed to analyze which areas of transcultural health care ATCs are proficient. Factors that affect cultural competence have been minimally assessed in the health care setting. Furthermore, gender, race, years of experience, and NATA district have not been compared to cultural competence. Therefore it is important to observe the impact these variables have on results of levels of cultural competence in athletic training. History of Athletic Training Athletics can be dated back to ancient Grecian times. We can assume that where there are athletics, there are also athletic trainers or paidotribes as they were referred to then. After the fall of Rome, athletic competition vanquished. It was not until the 19th Century when interest in athletics began to arise once again. During this time, gymnastics and a recreational form of football developed in Europe and the United States. Back then, coaches and physicians managed athletic injuries. Very few schools actually employed a “trainer” until the 1920’s. In this era, the profession saw opportunities arise at major universities for medical personal to work with active populations. Through the 1930’s, athletic trainers began traveling with the United States Olympic teams and shared ideas and techniques they learned via workshops and publications. As people began to hear about the birth of this new profession, many men were drawn to institutions where athletic training was practiced (Ebel, 1999). In 193 8, the first National Athletic Trainers’ Association was born during the Drake Relays at the University of Iowa. The association had two annual meetings, one at the Drake Relays (W estem Division), and the other at the Penn Relays (Eastern Division). Despite the hope of organization of the profession of athletic training, the United States became involved in World War II soon after the birth of the first NATA. During this time, athletic trainers were drafted and deployed as soldiers. Some athletic trainers utilized their skills by preparing men physically for battle and assisting with the rehabilitation of injured soldiers. Even though some athletic trainers remained active during the war, the NATA went bankrupt and in 1944, the first NATA no longer existed (Ebel, 1999). Although the first NATA disbanded during World War II, after the war, groups of athletic trainers began to form regional associations around the nation. However, these organizations needed a unifying unit, which lead to the birth of the new NATA in 1950. The organization slowly grew, hosting annual meetings, collecting dues, establishing district and executive representatives, and recruiting membership. In 1956, the first athletic training scholarly journal was established and a Code of Ethics was adopted in 1957 in accordance with the NCAA (Delforge & Behnke, 1999). After 20 years of growth, the NATA decided it was time for change and restructure. An organizational chart was developed, and the executive council was restructured and the position of NATA president was established. Also during this decade, the Board of Certification (BOC) Examination was implemented, the inclusion of women in the profession began, and state licensure was emerging. During the 1980’s, the NATA gained corporate sponsorship in Quaker Oats/Gatorade and became incorporated as the NATA Inc. The membership totaled over 10,000 and the budget of the corporation was rapidly growing. A headquarters was established in Dallas, Texas and a full-time professional staff was hired to run the operations of the NATA. Throughout the 1990’s, the NATA underwent major changes to operational procedures, rules, and bylaws. A new Policies and Procedures Manual was developed. The NATA also hired a company to assist in the assimilation of a strategic plan for the organization and profession. By 1999, the NATA enlisted over 25,000 members in good standing; a drastic change from 101 members 50 years prior (Ebel, 1999). As of March 2008, the NATA membership totals 31,272. Of these members, 25,683 are ATCs, which accounts for 82.1% of the certified population (NATA, 2008). These unique health care professionals now work in diverse settings, ranging from the traditional intercollegiate setting to emerging settings, such as performing arts or rodeo, specializing in the prevention, assessment, treatment and rehabilitation of injuries and illnesses. History of Ethnic Minorities in Athletic Training Diverse individuals have had to overcome challenges in all walks of life and the profession of athletic training is no different. In 1986, three individuals identified the following issues pertaining to the field of athletic training and presented them to the NATA Board of Directors: 1. The lack of quality health care available to the black athlete at predominantly black institutions. 2. The lack of minority athletic trainer memberships in the NATA. 3. The lack of educational materials and tools for minority athletic trainers. 4. The low number of certified minority athletic trainers. 5. The extremely low number of minority athletic trainers being employed in the profession. That same year, the Minority Athletic Trainers’ Committee was formed to improve these issues as well as serve as a voice for minority athletic training membership. The committee included a committee chairperson and appointed committee members. These members educated students and young adults on the profession of athletic training as well as recruited minorities into the profession. In 1989, the committee also published its first installment of a newsletter highlighting issues of minorities within the athletic training field. 10 After 1990, the committee began to falter due to lack of direction. A task force assigned to analyze these issues recommended to disband the Minority Athletic Trainers’ Committee and form a new council. The Ethnic Minority Advisory Council was formed in late 1991 with a chairperson and council. Throughout the next few years, the council made many positive steps with developing a mission, motto, and objectives and strategies, establishing a service award, compiling demographic data of NATA membership, and creating a minority Town Hall Meeting at the NATA convention. In 1999, the council’s name was changed to the Ethnic Diversity Advisory Council. In 2002, the NATA began to fund the council as a committee, and therefore the name once again changed to the present name of the Ethnic Diversity Advisory Committee (EDAC). The EDAC’s current statement is as follows: “The Ethnic Diversity Advisory Committee is dedicated to service, devoted to advocacy and committed to unity. We want to identify and address issues relevant to American Indian/Alaskan Natives, Asian/Pacific Islanders, Blacks (non- Hispanic), and Hispanics both in the health care arena and in the National Athletic Trainers' Association. We advocate sensitivity and understanding towards ethnic and cultural diversity throughout the profession and the association. We strive to enhance the growth and development of the NATA, and our objectives are designed to unify the association. So, join us in our efforts to promote service, advocacy and unity.” (EDAC, 2007). Despite the grth of diversity within the NATA, the numbers do not add up to the growing diverse population ATCs treat. In 2000, the US. Census Bureau estimated 30.6% of the United States population as minority (U .S. Census Bureau, 2004). In 2000, only 15% of the NATA membership was categorized as minority (NATA, 2007). The NCAA has been publishing a Race and Ethnicity report since 1999. In 2006, the NCAA released a six year trend in ethnic growth within intercollegiate athletics. During the 1999-2000 season, 25.1% of NCAA Division I, II, and III intercollegiate athletes were 11 minority (NCAA, 2006). In the 2004-2005 season, 25.65% of athletes were minority, a mere 0.55% increase. Despite this increase, the 2005 NATA membership statistics showed 13% minority membership, a 2% drop fi'om five years prior. The current makeup as of December 2006 of NATA certified members by ethnicity is as follows: 86.6% white, 2% black, 3% Hispanic, 0.4% American Indian/Alaskan Native, 3% Asian, 1% Other, and 4% Unspecified (NATA, 2007). This 13.4% minority membership compared to the populations we treat equals out to approximately one minority ATC for every two minority patients or athletes. Due to the lack of multicultural athletic trainers and the high number of multicultural athletes and patients ATCs care for, it is imperative that cultural competency be assessed within the profession. History and Evolution of Athletic Training Education and Curriculum Over the past 50 years, athletic training education and curriculum has gone through dramatic changes. The restructuring of educational practices and guidelines in both the classroom and clinical settings, eliminating the internship route to certification in order to increase quality control over entry-level education, adding new clinical proficiencies to reflect the diverse work settings and role delineation of athletic trainers, and the implementation of a clinical-instructor training program are just some of these modifications that have helped advanced the education of young athletic trainers (Geisler, 2003). The first athletic training curriculum was approved by the NATA in 1959, comprised primarily of coursework that already existed at four-year colleges and universities. This curriculum was similar to a physical education and health degree with 12 the exception of an athletic training class and laboratory. In 1969, the NATA developed the Professional Education Committee (PEC) to evaluate and recommend recognition of undergraduate education programs. Over the next two decades, the PEC improved coursework to specific skills for athletic trainers, developed a skills competency checklist, and formalized a list of learning outcomes for athletic training students (Craig, 2003; Delforge & Behnke, 1999). Throughout the 19803, the NATA approved and implemented a resolution that called for educational programs to offer a major field of study in athletic training, providing an academic major for athletic training students (ATS) for the first time in the history of the profession. At this time, there were two routes recognized to certification by the NATA; graduation from an athletic training major fiom a college or university, or completion of an internship in athletic training. In 1989, the NATA recognized the Board of Certification Inc. as an independent entity to provide a certification program for entry- level athletic trainers and recertification standards for ATCs. The certification program was designed to establish standards for entry into the athletic training profession and remains the only accredited certifying body for athletic trainers in the United States (Board of Certification, 2008). At this time, both athletic training curriculum and internship allowed individuals to sit for the BOC Examination, the certifying exam for the profession of athletic training. The Joint Review Committee on Educational Programs in Athletic Training (J RC- AT) was developed in October of 1991 under the Commission on Accreditation of Allied Health Profession Programs (CAAHEP), charged with the review and accreditation of educational programs in athletic training. As athletic training curriculum and education 13 advanced, the internship route to certification was eventually eliminated. As of January 2004, ATSs must go through a four-year accredited institution to be eligible to sit for the BOC Exam (Craig, 2003). Effective June 30, 2006, the JRC-AT became independent of CAAHEP and became CAATE, the new certifying body for entry-level athletic training education programs (AT EP). The Commission on Accreditation of Athletic Training Education defines the standards and practices for all accredited ATEPs in the nation, currently overseeing 343 undergraduate and 18 entry-level graduate programs (CAATE, 2008). The CAATE’s purpose is to maintain and assure that the quality and content of all accredited ATEPs are consistent with the Standards established (CAATE Overview, 2008) The CAATE Standards are divided into three sections. Section I contains information on General Requirements for Accreditation. This section includes the function and qualification guidelines on personnel such as program directors, instructional faculty and staff, and clinical faculty and staff. It also includes information on sponsorship of a program, physical, financial, instructional, therapeutic, rehabilitative, and emergency care resources, operational policies and fair practices, health and safety, and student outcomes. Information on curriculum and instruction and clinical education are also included in Section 1. Section II of the CAATE Standards focus on Administering and Maintaining Accreditation. The focus here is on application to become an accredited program and the process a potential program can expect. Guidelines for maintaining accreditation and annual reporting fall into Section 11 along with administrative actions CAATE may take on a program if not in compliance with the Standards. Section III is the Athletic Training 14 Standards Glossary. This section provides definitions for terms used in athletic training education as well as abbreviations for commonly used terms (CAATE Standards, 2008). The CAATE Standards are inclusive of the National Athletic Trainers’ Association’s Education Council’s Educational Competencies and Clinical Proficiencies. Currently in its fourth edition, the NATA competencies are designed to define the skills required of an entry-level ATC to provide athletic training services to patients of differing age, gender, work, lifestyle and need (N ATA Competencies, 2007) The competencies are divided into Foundational Behaviors of Professional Practice, and 12 content areas comprising the knowledge and skill set of the entry-level ATCs. The 12 areas are Risk Management and Injury Prevention, Pathology of Injuries and Illnesses, Orthopedic Clinical Exam and Diagnosis, Medical Conditions and Disabilities, Acute Care of Injuries and Illnesses, Therapeutic Modalities, Conditioning and Rehabilitative Exercise, Pharmacology, Psychosocial Intervention and Referral, Nutritional Aspects of Injuries and Illnesses, Health Care Administration, and Professional Development and Responsibility. Each content area is subdivided into behavioral classifications of cognitive domain, or knowledge and intellectual skills, psychomotor domain, or manipulative and motor skills, and clinical proficiencies, or decision-making and skill application. The Foundational Behaviors are basic behaviors that should permeate every aspect of professional practice and should be incorporated into every educational aspect of athletic training education. Cultural competence is included in the Behaviors, stating the ATC should understand the cultural differences of patients’ attitudes and behaviors toward health care, demonstrate knowledge, attitudes, behaviors, and skills necessary to achieve optimal health outcomes for diverse patient 15 populations, and demonstrate knowledge, attitudes, behaviors, and skills necessary to work respectfully and effectively with diverse populations and in a diverse work environment (N ATA, 2006). It could be asked where cultural care in athletic training falls into entry-level education among ATSs. The Matrix 4th Edition Educational Competencies addresses these issues within the content areas of Psychosocial Intervention and Referral and Health Care Administration. Entry-level ATCs are expected to “describe the theories and techniques of interpersonal and cross-cultural communication among athletic trainers, their patients, and others involved in the health care of the patient.” They must also be able to “identify common human resource policy and federal legislation regarding employment,” which includes affirmative action and equal employment opportunity (Educational Competencies Matrix, 2007). Because cultural diversity education and care is included in the competencies, it can be assumed that CAATE accredited ATEPs have included a minimal amount of multicultural education or diversity training. However, there is currently no guideline set forth by the NATA, Education Council, or CAATE that states how this education or training is to be delivered. It may be in the form of a college course, content discussed within acollege course, or other form of training. This training may or may not be athletic training specific as each individual ATEP decides the appropriate way to deliver the material. It is fair to say that Program Directors have a difficult job in weighing each competency and how much time and effort should be spent on teaching the skill set to ATSs. Many times, education of multicultural issues may take a ‘back seat’ to other skills, such as clinical evaluation skills. With the learning over time approach to athletic 16 II training education, skills are taught, re-taught, and applied in the clinical setting. It is easier to utilize this approach to tangible skills, such as an anterior drawer test for the anterior cruciate ligament integrity, rather than a psychosocial competency of cross- cultural communication. There is no guideline to how multicultural education is applied to learning over time. It is questionable how often diversity issues are discussed throughout an ATEP. Geisler (2003) makes suggestions on how to incorporate cultural issues into the classroom setting by using simple class activities to promote dialogue among ATSs to explore cultural issues starting with personal ethnic and cultural backgrounds. He also states that diversity is much more than just race but includes religion, sex, class, sexuality, and a multitude of ethnic cultures (Geisler, 2003). Cultural education may also be neglected by some faculty because they may not know how to approach these issues in the classroom. Some ATEPs require ATSs to enroll in a diversity education course offered at the sponsoring college or university. Geisler (2003) suggests courses that focus on cultural anthropology, women’s studies, African American issues, philosophy, religious studies, and other subjects that are universally offered within an institution will help start students on a critical and transforrnative intellectual path. Ekelman, Belle-Haas, Bazyk, and Bazyk (2003) examined occupational therapy and physical therapy students’ learning methods in cultural competency. Results of the study revealed immersion learning is the key component to multicultural education. With this method, students are completely removed fi'om their familiar lifestyle and environment so that they must interact with others who are different in unfamiliar surroundings (Ekelman, Bello-Haas, Bazyk, & Bazyk, 2003). 17 Another theory on diversity education is Pederson’s multicultural development sequence of awareness, knowledge, and skill (Pederson, 1994). Other programs following this theory may offer diversity education seminars that discuss specific cultural issues or lecture on diversity issues within a major course. This may be the most effective way to address cultural competencies, as the delivery is specific to athletic training, thus allowing the ATS to identify and relate to situations they are likely to encounter within their profession. Ultimately, the decision on multicultural health care delivery is up to each individual institution. Zeller (1995) states that it is the responsibility of the educational institutions of the United States to nurture cultural sensitivity by providing students with the opportunity to explore and examine other cultures, as well as their own, in health care education. Cultural competence is essential when encountering diversity in any setting and requires preparation through formal education (Sargent, Sedlak, & Martsolf, 2005). It is therefore the ethical and professional responsibility of the athletic training educator to prepare competent athletic trainers who are socially conscious, civic minded, and critically aware of their roles in society (Hannam, 2000). Culturally Competent Care Drs. Schim and Doorenbos are the original developers of the Cultural Competency Assessment Inventory (CCA). The CCA was designed around four basic constructs that constitute the main pieces of a cultural competence puzzle at the health care provider level including cultural diversity, cultural awareness, cultural sensitivity, and cultural competence. All four pieces fit together to model the complete holistic construct of culturally congruent care (Schim, Doorenbos, Benkert, & Miller, 2007). 18 Cultural diversity is commonly thought of as only an issue of race. In fact, diversity is the difference between groups based on distinguishing factors such as race, ethnicity, national origin, sexual orientation, gender, ideology, language, disability and generation. Even if an ATC shares the same ethnic or racial background with an athlete or patient, there are still other aspects of diversity that remain unaddressed. Cultural awareness presumes that there is some reality to be contemplated and a corresponding capacity for processing knowledge (Schim, Doorenbos, Benkert, & Miller, 2007). This means that awareness requires not only the existence of a fact but a knowledge and recognition of those facts. For example, awareness is knowing religious practices commonly influence food choices, but also that individuals within religious groups may vary with these choices. When utilizing cultural awareness, the ATC can use the appropriate assessment questions and customize care to meet specific individuals in culturally appropriate ways. Cultural sensitivity involves the recognition of personal attitudes, values, beliefs and practices (Schim, Doorenbos, & Borse, 2006). It is the self-exarnination and in-depth exploration of one’s own cultural background (Campinha-Bacote, 1998). This also includes approaching an individual patient or athlete with humility and taking a learner role rather than assuming a position of sufficient knowledge regarding any particular group. Also encompassed in this puzzle piece is nonverbal communication, careful use of silence and touch, respect for conversational distance and use of language patterns in an appropriate manner when providing sports medicine care (Schim, Doorenbos, Benkert, & Miller, 2007). 19 The fourth and final construct of cultural competence is the incorporation of personal cultural diversity experiences, awareness, and sensitivity into everyday athletic training practice (Schim, Doorenbos, & Borse, 2006). Competence is not an end point, nor the intent for eventual mastery, but denotes a set of learned, practiced, and evolving behaviors to be approached with cultural humility (Tervalon & Murray-Garcia, 1998). Therefore, this can change over time in response to an individual’s experiences and education. The four pieces of the cultural competence puzzle represent the four main constructs on the provider level when providing care to diverse populations. They have been arranged in a nonlinear and interconnected nature, all necessary to achieve culturally competent care, the incorporation of all four pieces of cultural competence (Schim, Doorenbos, & Borse, 2006). The Cultural CCA has been developed from this model. Assessment Tools Aside from the CCA, there are few existing inventories to measure cultural competency. A commonly used tool available to assess culturally competent care is Campinha-Bacote’s Inventory for Assessing the Process of Cultural Competence- Revised (IAPCC-R). The IAPCC-R is validated through numerous studies by experts in the field of multicultural care (Olt & Emami, 2006; Mabunda & White, 2006). The inventory also has 20 studies nationally and internationally testing reliability, reporting a Cronbach’s Alpha as high as =.90 (Spencer & Cooper-Brathwaite, 2003). The IAPCC-R has been used once in the field of athletic training. Maurer-Starks (2005) assessed levels of cultural competence among ATSs, discovering that 144 (91.7%) of 157 students 20 earned total IAPCC-R scores indicating they were culturally aware, and the remaining 13 (8.3%) indicating they were culturally incompetent. No students earned scores indicating they were culturally competent or proficient. Although the IAPCC-R is a proven tool, it is written at an advanced reading level and requires the reader to switch between various response levels simultaneously, which may be problematic for some participants. Another widely used instrument in this area of research is the Cultural Self- Efficacy Scale (CSES) (Bemal & Froman, 1987). The CSES has been proven to have very high reliability, ranging from 97-98 (Smith, 1998), as well as validity. However, this inventory is not linked to any cultural competency model and is very long, containing 58 items. It is sometimes used with the Cultural Attitude Survey-Modified (Rooda, 1993). This inventory, used primarily within nursing, was designed to measure attitudes towards only three specific ethnic groups, including Afiican-Americans, Hispanics, and Asian Americans. However, specific attitudes are not desired towards a single ethnic group for this study. The purpose of this study is to discover a baseline cultural competency level. Thom, T riado, Woon, and McBride (2006) implemented the Patient-Reported Physician Cultural Competence (PRPC) Inventory to assess pre-test, post-test scores in 53 primary care physicians. This study implemented four diverse health care clinics to test the effectiveness of diversity training. The PRPC, originally designed by Thom and Triado (2006), was to investigate associations between provider cultural competency and health care processes and outcomes. This inventory, however, allows patients to assess the cultural levels of their primary providers. It does not provide baseline data for the practitioner’s levels of cultural competence and is used to specifically assess a cultural 21 training program designed by the authors. There is also not much published data on the inventory. Other inventories include the Cultural Competence Self-Assessment Questionnaire (CCASQ) (Mason, 1995), the Program Self-Assessment Survey for Cultural Competence (Weiss & Minsky, 1996), or the Cultural Competence Assessment Tool (Western Interstate Commission on Higher Education, 1996) all used within health care fields. However, these inventories are specifically designed to measure levels of cultural competence within specific programs and not for widespread use. For instance, the CCASQ is used to assist agencies working with children with disabilities. Therefore, no psychometric properties are available for these inventories. No such inventory exists specific to athletic training. The CCA was designed to be all-inclusive of various allied health professions. Over the past five years, the CCA has been used in numerous studies identifying the cultural competence of various health care fields. It is a self-administered inventory consisting of 30 questions on a 7-point Likert scale that assesses the four constructs of culturally congruent care: cultural awareness, competence, diversity, and sensitivity (Schim, Doorenbos, Miller, & Benkert, 2003). Proven reliable and valid, the CCA is easy to read and short, thus able to be completed in about 15 minutes. The CCA is one of the few generic culturally competent models that can be used with differing professions. Because athletic training has no cultural competency assessment tool, the CCA can be used in a generic fashion to provide a baseline for levels of culturally competent care among ATCs. 22 The need for development of a culturally competent system of care is necessary in the field of sports medicine due to the ever growing and changing diverse population ATCs care for. A tool must be used to assess levels of cultural competence in order to identify strengths and weaknesses within the profession. The CCA, proven valid and reliable, will assist athletic training governing bodies in the development and implementation of more defined curricula to prepare future ATCs for culturally competent health care services. 23 CHAPTER 3 METHODS The purpose of this study was to assess the cultural competence levels of ATCs in their delivery of health care. This study also examined the relationship between cultural competence and gender, race, years of experience, and NATA district. Research Design This research was a survey and therefore a non-experimental design. The independent variables were gender, race, years of experience, and NATA district. The dependent variable was level of cultural competence as measured by the CCA. Sample Participants were a board certified athletic trainer and a member of the NATA. Participants represented a wide variety of race, years of experience, and NATA districts (Appendix A). Both males and females were included in this study. Participants were contacted via electronic mail by addresses purchased from the NATA. Participation was voluntary and only those subjects who completed and returned the survey were included in the final analysis of data. As of September 3, 2007, 26,234 ATCs meet the criteria for this study (NATA, 2007). Patten (2005) suggests for survey research on large populations, 800 or more participants should be used. However, the survey was distributed to all eligible participants. Due to membership rights through the NATA, members may elect not to receive surveys, therefore, the survey was distributed to 13,568 student certified, international certified, and regular ATCs. 24 Instrumentation Cultural Competency Assessment Inventory (CCA). To assess cultural competence among ATCs, the CCA (Appendix C) was distributed to ATCs throughout the nation. Over the past five years, the CCA has been used in numerous studies identifying the cultural competence of various health care fields. It is a self-administered inventory consisting of 30 questions on a 7-point Likert scale that assesses the four constructs of culturally competent care: cultural awareness, competence, diversity, and sensitivity (Schim, Doorenbos, Miller, & Benkert, 2003). Cultural diversity experience is addressed by asking participants to identify types of culturally and ethnically diverse athletes and patients they have cared for in the past 12 months. The two subscales of the CCA, cultural awareness and sensitivity (CAS) and cultural competence behavior (CCB) assess the remaining constructs by asking participants to respond to statements made about diversity and health care. For example, a participant may select a response of strongly agree to strongly disagree with the option of no opinion to the following statement; “Many aspects of culture influence health and health care.” Wording will be edited to represent the athletic training population. The CCA also includes demographic questions pertaining to participant’s gender, race, years of experience, NATA district, work setting, level of education, and prior cultural care education. Psychometric Properties of CCA. Previous research has demonstrated the CCA to be proven valid and reliable. Two separate panels of national experts in the field of multicultural health care representing nursing, social work, medicine, spiritual care, assistants/aids, volunteers, anthropology, sociology, psychology, gerontology, education, and law established content and face validity of the CCA (Schim, Doorenbos, Miller, & 25 Benkert, 2003). Construct validity and factor analysis for each CCA item was established by conducting a face-to-face field test of the instrument and through pilot testing (Schim, Doorenbos, Miller, & Benkert, 2003). Further validity was also addressed by comparing the CCA with the Inventory for Assessing the Process of Cultural Competence among Health care Professionals (IAPCC) and the Constructs of Competence Puzzle (Schim, Doorenbos, Benkert, & Miller, 2007). The CCA was revised for the athletic training population and validated by experts from the primary investigator’s thesis committee. Reliability has been established with internal consistency reliability Cronbach’s Alpha ranging from r=0.89 (Doorenbos, Schim, Benkert, & Borse, 2005; Schim, Doorenbos, & Borse, 2005; Schim, Doorenbos, Borse, 2006) to r=0.92 (Schim, Doorenbos, Miller, & Benkert). Test-retest reliability has also been established at r=0.85 (Doorenbos, Schim, Benkert, & Borse, 2005). Data Collection Procedures Prior to data collection, the institutional Internal Review Board approved this study. The CCA was distributed to eligible participants electronically through SurveyMonkey.com through email addresses purchased through the NATA. SurveyMonkey.com is an online system that allows researchers to develop and distribute survey research by creating a webpage for participants to complete surveys by accessing a link provided via electronic mail. The website database then collects responses and allows researchers to download and analyze data. By completing and returning the online survey, it was implied that participants consented to participate in the study. All responses were returned to the survey website as anonymous data. The e-mail contained an overview and explanation of the study (Appendix B), as well as a hyperlink to the 26 survey. Participants needed approximately 15 minutes to complete the CCA. The inventory was designed to be an independent, one time self- administered survey to be completed on a computer with intemet access. The participants answered 30 questions on a 7-point Likert scale assessing levels of cultural competence. Participants were allowed to withdraw at any time without penalty and allowed to skip questions. Testing Schedule Due to academic and grant deadlines, the questionnaire was available for completion for one month from November 19, 2007 at 12:00pm through December 17, 2007 at 12:00pm. The questionnaire was distributed through SurveyMonkey.com and was available 24 hours a day for the one month testing period. An email was sent after two weeks to remind participants to complete the inventory. Data Management Data was recorded electronically through SurveyMonkey.com as each participant completed the inventory. The data was password protected and only the primary investigator and a faculty advisor had access and could view individual responses. There was no identifiable information, thus all individual responses remained anonymous. Only group results were reported to the EDAC. Any data printed was placed in a locked file cabinet in the locked primary investigator’s office. Data Analysis Demographic information and scores from the CCA were summarized using descriptive data. All data collected was nominal data. The CCA utilizes a 7-point Likert scale. A higher score (7) indicates a healthcare professional is operating at a high level of cultural competence, while a low score (1) indicates the participant has a low level of 27 cultural competence. Frequency distributions were performed on each response. The mean of the CCA’s subscales, the Cultural Awareness and Sensitivity (CAS) and Cultural Competence Behavior (CCB), serve as the total score for the CCA. Levene’s test for equality of variance was performed to determine normality of data. Separate univariate analysis of variance were conducted on each of the independent variables (gender, race/ethnicity, district, or years of experience) to determine cultural competence. The statistical significance level was set prior at p<0.05. Data was analyzed using the Statistical Package for the Social Sciences (SPSS) 15.1 software. Threats to Internal Validity This study possessed threats to internal validity, but efforts were made to minimize these threats. A time threat of history may have been a threat to internal validity. Any cultural experiences, or lack thereof, that participants may have been involved in prior to this study threaten internal validity. This is difficult to control because past cultural experiences were not assessed. Due to the inventory being self- administered and electronic, participants may have completed the research in any setting, such as work or home. For this reason, it is possible a historical event may occur while completing the inventory. However, due to the relatively short 15 minutes needed to complete the inventory, this threat should be controlled. Another time threat of maturation may have affected the results of this research. Participants’ age or years of experience may have had an effect on responses. More experienced ATCs may have had varying beliefs on cultural health care. Because years of experience was a hypothesis, this threat was minimized. Participants may also have been fatigued or distracted over time while completing the inventory. However, a shorter testing period assisted in 28 reducing this threat. Instrumentation decay and expectancy may have been a threat due to the wording of the survey. An expert committee reviewed and approved the inventory revisions. Due to the survey being distributed electronically, a computer or intemet malfirnction may have occurred, threatening internal validity. This was hard to control for due to lack of a testing site. To establish baseline data, the instrument was distributed to all eligible participants. Therefore, mortality was a threat. To control for this, a follow-up email was sent to all eligible participants two weeks after the instrument became available on SurveyMonkey.com, reminding participants they had two weeks left to complete the survey. Pretest reactivity and group threats were non-applicable. Threats to External Validity Reactive or interactive effects of testing were one threat to external validity. Cultural issues may be somewhat sensitive; therefore participants may have responded to questions differently because the data was being analyzed. There was no pretest or posttest involved in this research; as a result this was difficult to control due to the nature of the study. The interaction of selection biases may have also caused a threat. Participants with certain characteristics or of specific race may have responded to questions differently than other participants. This may be controlled for by a random selection, however, baseline data is needed and therefore this research included all eligible participants. Finally, certain populations within the participant pool, such as minority ATCs, may have been more inclined to complete and return the inventory versus majority due to past experiences or interest in the research question. This threat may skew results obtained through the research. However, this is one of the research questions. 29 CHAPTER 4 RESULTS This research study was conducted to investigate the level of cultural competence of ATCs. The following describes the demographic information and the CCA’s subscales, the CAS and CCB, which will serve as the total score for the CCA. In addition, this chapter will describe cultural competence of ATCs between race, gender, years of experience, and district. Demographic Information A total of 3,102 participants completed the survey for a response rate of 22.86%. One hundred and fifty nine certified athletic trainers were excluded from the study due to incomplete data. A slightly higher number of females (1490/2931 [50.8%]) completed the CCA compared to males (1441/2931 [49.2%]). Participants averaged 11.2 (i 9.87) years of experience as an ATC. The average age of participants was 35.3 (i 9.41) years. The majority of participants consider themselves White/Caucasian/European American (2643/2933 [90.1%]), followed by other (86/2933 [2.9%]), Hispanic/Latino (61/2933 [2.1%]), Asian (57/2933 [1.9%]), and Black/African American (57/2933 [1 .9%]) (see Table 4-1). Those ATCs that considered themselves as “other” mostly described their race/ethnicity as multiracial or mixed. 30 Table 4-1 Demographics by Race and Gender Race Male Female Total Hispanic/Latino 35 26 61 White/Caucasian/European American 1285 13 53 263 8 Black/Afiican American 20 37 57 American Indian/Alaska Native 11 3 14 Asian 34 23 57 Native Hawaiian/Pacific Islander 3 2 5 Arab American/Middle eastern 6 4 10 Other 44 42 84 Total 1438 1490 2928 *Due to variations in participant response, totals are not exact. Most of the participants were members of District Four (676/2906 [23.3%]), followed by District Two (388/2906 [13.4%]), District Nine (347/2906 [l 1.9%]), and District Three (339/2906 [l 1.7%]) (see Table 4-2). 31 Table 4-2 Demogaphics by Districts and Race and Gender District Hispanic/ White/ Black/ American Asian Latino Caucasian Afiican Am. Indian/Alaskan District One 0 146 1 0 4 District Two 3 357 9 l 3 District Three 4 304 12 3 5 District Four 7 63 1 10 2 10 District Five 3 262 1 2 0 District Six 7 149 3 1 3 District Seven 5 172 3 3 2 District Eight 17 147 3 0 11 District Nine 12 3 13 15 0 2 District Ten 2 128 0 2 5 lntemational 0 7 0 O 1 1 Total 60 2,616 57 14 56 32 Table 4-2 Demographics by Districts and Race and Gender Continued District Hawaiian/ Arab Am./ Other Male Female Total Pacific Islander Middle east. District One 0 0 2 66 87 153 District Two 0 2 13 190 198 388 District Three 0 2 9 163 176 339 District Four 0 1 14 31 1 364 675 District Five 0 0 7 141 134 275 District Six 1 2 6 88 85 173 District Seven 2 0 8 104 90 194 District Eight 0 3 17 94 103 197 District Nine 1 0 3 140 155 345 District Ten 1 0 5 70 73 143 lntemational 0 0 1 8 11 . 19 Total 5 10 85 1425 1476 2901 *Due to variations in participant response, totals are not exact. Almost two-thirds of the participants earned a Masters degree (1816/2930 [62.0%]), followed by Bachelors (975/2927 [33.3%]), and Doctorate (138/2927 [4.7%]). In addition, almost two-thirds of the participants graduated from an accredited program (1829/2918 [62.7%]) compared to the former internship route to certification (1089/2918 [37.3%]). The most common employment position held by participants was college/university (1072/2928 [36.6%]), followed by secondary school only (681/2928 [23.3%]), clinic/secondary school (523/2928 [17.9%]), and clinic only (182/2928 [6.2%]) 33 (see Table 4-3). ATCs that selected “other” described their job setting as graduate athletic training students, physical therapy students, or physician’s assistant students. In addition, participants in the ”other” category also included ATCs that held dual positions (Wellness Coordinator/ Secondary School, Hospital/Secondary School), duel credentialed ATCs (physical therapists/physician’s assistants), sales, and unemployed ATCs. 34 Table 4-3 Demographics by Employment Setting and Race and Gender Employment Hispanic/ White/ Black/ American Asian Setting Latino Caucasian Afiican Am. Indian/Alaskan College/ 25 956 29 5 22 University Clinic/ Secondary 3 498 6 1 4 School Clinic Only 2 166 1 . 2 5 Secondary 1 7 607 l 3 5 9 School Only Health/Fitness 0 30 O 0 4 Hospital 2 71 l O 0 Professional 5 86 6 0 6 lndustrial/ l 35 0 1 2 Occupational Corporate 0 15 0 0 0 Amateur/Reel 0 1 1 0 O 1 Youth Military/Law/ 1 20 0 0 0 Govt. Other 4 141 1 0 4 Total 60 2,636 57 14 57 35 Table 4-3 Demographics by Employment Setting and Race and Gender Continued Employment Hawaiian/ Arab Am./ Other Male Female Total Setting Pacific Island Middle east. College/ 2 3 30 531 539 1070 University Clinic/ Secondary 0 2 8 243 278 52 1 School Clinic Only 1 0 5 79 103 182 Secondary 2 2 25 332 349 681 School Only Health/Fitness 0 0 5 24 1 5 39 Hospital 0 0 3 32 45 77 Professional 0 1 3 94 14 108 Industrial/ 0 0 1 22 18 40 Occupational Corporate 0 0 0 7 8 15 Amateur/Rec./ 0 1 0 4 9 13 Youth Military/Law/ 0 0 2 13 10 23 Govt. Other 0 1 4 57 97 154 Total 5 10 86 1438 1485 2923 *Due to variations in participant response, totals are not exact. 36 Over half of participants had prior diversity training (1576/2927 [53.8%]). Participants gained their diversity training in an employer sponsored program (988/ 1683 [58.7%]), college course (503/ 1683 [29.9%]), professional conference or seminar (404/1683 [24.0%]), separate college course for credit (330/1683 [l9.6%]), continuing education offering (145/1683 [8.6%]), other diversity training types (121/1683 [7.2%]), and on-line education (116/1683 [6.9%]). Those that selected “other diversity training types” listed military diversity training, teaching experience, and living/traveling abroad as the most common methods. When asked if this diversity training was specific to athletic training, the majority of participants stated it was not specific (1712/1908 [89.7%]). The most common racial/ethnic groups participants reported working with were White/Caucasian athletes or patients (2896/2940 [98.5%]), followed by Black/African American (2699/2940 [91.8%]), Hispanic/Latino (2423/2940 [82.4%]), and Asian (1993/2940 [67.8%]). The most common special population groups participants treated were different religious backgrounds (2180/2670 [81.6%]), followed by gay, lesbian, bisexual and transgender (1772/2670 (66.4%]), mentally or emotionally ill (1339/2670 [50.1%]), and physically challenged or disabled.1236/2670 [46.3%]) (see Table 4-4). Those that selected “other” reported working with the elderly, disordered eating, obesity, low socioeconomic status, victims of abuse, non-English speaking, and illegal immigrant/refugee special populations. 37 Table 4-4 Demographics by Racial/Ethnic Group and Special Population Treated Percentage encountered Total percentage of Athlete/Patient Population by ATC population treated Racial/Ethnic Group Hispanic/Latino 82.4% 12.24% White/Caucasian 98.5% 62.25% Black/African American 91.8% 19.43% American Indian/Alaska Native 24.0% 2.43% Asian 67.8% 5.28% Native Hawaiian/Pacific Islander 21.3% 2.23% Arab American/Middle eastern 34.6% 2.51% Other 4.5% 2.52% Special Population Group Mentally or emotionally 111 50.1% 5.47% Physically Challenged/Disabled 46.3% 8.91% Homeless/Housing Insecure 19.5% 3.5% Substance Abusers/Alcoholics 47.7% 7.81% GLBT 66.4% 7.43% Different religious backgrounds 81.6% 27.39% Other 3.9% 29.54% 38 Cultural Competence Assessment Hypothesis 1 : AT Cs are culturally competent within their delivery of health care services. Results revealed that ATCs self-reported a mean of 4.52 (i 0.63) out of 5.0 (90.4%) for overall cultural competence assessment After completing the CCA, participants scored an overall mean of 4.80 (i 2.08) out of 7.0 (68.5%), including a mean of 5.65 (i 1.38) on the CAS (80.7%) and 3.95 (i 2.16 ) on the CCB (56.4%). Therefore, ATCs self-reported a high level of cultural competence; however, results indicated that ATCs operate at a moderate level of cultural competence. Hypothesis 2: There is no diflerence in the level of cultural competence between male and female AT Cs. Results of a univariate analysis of variance revealed a significant difference between genders [F(1,2929)=76.28, p=.000] (see Tables 4-5 and 4-6). Specifically, female ATCs (m=6.01, SD=.54) were more culturally competent compared to male ATCs (m= 5.83, SD=.58). Table 4-5 Means and Standard Deviation for Certified Athletic Trainers Total C CA Scores by Gender Gender N Mean Std. Deviation 95% CI Lower 95% CI Upper Males 1441 5.837 .015 5.808 5.866 Females 1490 6.017 .014 5.989 6.046 Table 4-6 Univariate Analysis of Variance by Gender Type III Sum df Mean F p Partial Eta of Squares Square Squared Gender 23.796 1 23.796 76.284 .000* .025 *p_<_0. 05 39 Hypothesis 3: Minority AT Cs will experience higher levels of cultural competence than majority (White/CaucasianO AT Cs. Results of a univariate analysis of variance indicated a significant difference between race [F(1,2925)=4.46, p=.000] (see Tables 4-7 and 4-8). The highest cultural competence scores were reported for multiracial/other and African Americans groups. The least culturally competent group was American Indian/Alaska Native. White/Caucasian/, considered majority, scored mid-range. Table 4-7 Means and Standard Deviation for Certified Athletic Trainers Total CCA Scores by Race Race N Mean Std. 95% CI 95% CI Deviation Lower Upper Hispanic/Latino 61 5.9376 .44921 5.796 6.079 White/Caucasian 2643 5.9326 .56891 5.91 1 5.954 Black / Afiican 57 6.0367 .45061 5.891 6.183 American American Indian/ 14 5.5103 .5535] 5.215 5.805 Alaska Native Asian 57 5.6187 .5146] 5.473 5.765 Native Hawaiian/ 5 5.7718 .5372] 5.278 6.265 Pacific Islander Arab American/ 10 5.9006 .69659 5.552 6.250 Middle eastern Multiracial/Other 86 6.0430 .52981 5.924 6.162 Total 2933 5.9294 .5652] 5.063 6.057 40 Table 4-8 Univariate Analysis of Variance by Race Type III Sum df Mean F p Partial Eta of Squares Square Squared Race 9.890 7 1.413 4.459 .000* .01 1 *p50. 05 Hypothesis 4: There is no difference in the level of cultural competence between newly certified (0-5 years) and experienced (>5years) AT Cs. There were no significant differences between years experience of certified athletic trainers [F(1,2932)=2.81, p=.09] (see Tables 4-9 and 4-10). Table 4-9 Means and Standard Deviation for Certified Athletic Trainers Total C CA Scores by Years of Experience Years of Experience N Mean Std. Deviation New ATCs 1172 5.9069 .56086 Experienced ATCs 1762 5.9427 .56856 Total 2934 5.9284 .56567 Table 4-10 Univariate Analysis of Variance by Years of Experience Type III Sum df Mean F p Partial Eta of Squares Square Squared Experience .902 l .902 2.8 .093 .001 *p50.05 Hypothesis 5: There is no diflerence in the level of cultural competence of A T Cs by NA TA district. There were no significant differences between the eleven districts [F(|2895)=1 .48, p=.l4l] (see Tables 4-11 and 4-12). 41 Table 4-11 Means and Standard Deviation for Certified Athletic Trainers Total C CA Scores by District District N Mean Std. Deviation District One 153 5.9763 .49834 District Two 388 5.8978 .55464 District Three 339 5.8748 .57466 District Four 676 5.9508 .55070 District Five 275 5.9331 .55208 District Six 173 5.8924 .53722 District Seven 195 5.9652 .54933 District Eight 198 6.9669 .6654] District Nine 347 5.9076 .57605 District Ten 143 5.9950 .58875 lntemational 19 5.6861 .63586 Total 2906 5.9284 .56522 Table 4—1 2 Univariate Analysis of Variance by District Type III Sum df Mean F p Partial Eta of Squares Square Squared District 4.714 10 .471 1.478 .141 .005 *p50. 05 42 CHAPTER 5 DISCUSSION No prior research has assessed the interactions of ATCs with racially and ethnically diverse athletes and patients, and aside from a handful of editorials and periodicals, this issue is rarely discussed within the profession of athletic training. Furthermore, levels of cultural competency have never been evaluated among ATCs. Key Findings The findings of this study revealed ATCs were moderately culturally competent within the delivery of health care services. Half (53.8%) of the participants were involved in prior diversity training with only 10.3% involved in athletic training specific training. This is most likely due to the largely diverse clientele ATCs treat on a daily basis and the multidisciplinary synthesis of various medical specialties and disciplines assembled into a viable health service option for physically active populations (Geisler, 2003). Furthermore, ATCs self-reported themselves as very competent, whereas actual results found ATCs to be moderately competent. This may be due to the fact that ATCs are more aware to cultural issues as measured on the CAS, but behaviors do not necessarily reflect the awareness and sensitivity as measured on the CCB. Because providers with diversity training score significantly higher on the CCA compared to those without training, diversity education is needed in the athletic training profession (Schim, Doorenbos, & Borse, 2005). Furthermore, these findings are lower than the nursing profession. Nurses were found to be culturally competent, scoring 85% on the CCA (Doorenbos, Schim, Benkert & Borse, 2005). Other studies did not assess competence levels, but rather found that prior cultural competence training and level of educational 43 attainment were a significant indicator of higher levels of cultural competence in nursing (Schim, Doorenbos, & Borse, 2005). Female ATCs scored higher on cultural competency levels than male ATCs. A possible explanation may be that women are considered more liberal than men (W elch, 1985). For example, Welch (1985) assessed gender voting patterns over a four year term in the U. S. House of Representatives and found that women consistently vote in a more liberal direction then men. Another study which assessed views on diversity found that Caucasian men perceived the organization they worked for as more fair and inclusive than Caucasian women and racial/ethnic minority men and women. Caucasian women and racial/ethnic minority men and women also saw more value in and felt more comfortable with diversity than Caucasian men (Barak, Cherin, & Berkman, 1998). This is not surprising considering the adversity women and minorities have had to overcome the past century in seeking global equality. Another explanation for these findings may be due to a theory provided by Baron-Cohen (2003) who states that the female brain is programmed to empathize more than the male brain. With a sensitive issue such as cultural diversity, it is not unrealistic to believe some participants may have related questions to life events or empathize with certain situations therefore causing them to respond in a more culturally conscious manner. This study found some minority ATCs were more culturally competent than Caucasian ATCs. The most culturally competent group was Black/Afiican American followed multiracial/other, Hispanic/Latino, and White/Caucasian. It can be assumed that multiracial ATCs would have a broader perspective on race and ethnicity. For example, many participants reported being raised in a biracial or multiracial home with 44 potentially more exposure to ethnically and racially diverse opportunities and education than those ATCs that grew up in a single race home. Although ethnicity does not correlate exactly with race, it does follow racial lines, so one can also assume that minority groups, such as Black/Afiican American and Hispanic/Latino, may have a better understanding of cultural issues related to athletic training care than their White/Caucasian counterparts. Arab American/Middle Eastern, Native Hawaiian/Pacific Islander, Asian, and American Indian/Alaskan Native groups rounded out the lower end of cultural competency levels. One explanation may be that Asians and Hawaiian/Pacific Islander groups are not as assimilated into the White Anglo-American Mainstream as other cultural groups due to tendencies to live within their own culture, value, and ethnic system (Kim, McLeod, & Shantzis, 1998). Although this may account for lower competency scores for the general racial group, because of the diversity of clients ATCs treat and work with, it is improbable that an Asian or Hawaiian/Pacific Islander ATC has remained segregated throughout his or her education and career due to the lack of minorities within the profession and educational programs. Lower competency scores may also be associated with the types of patients and athletes certain ATCs treat. If an ATC treats clients primarily within their own ethnic or racial group, scores may be lower. Research supports that patients prefer health care providers within their same race or ethnic group (Cooper-Patrick et. al., 1999), which may also be true with ATCs. Cooper- Patrick et. a1. (1999) found that patients in race-concordant relationships with their physicians rated their visits significantly more participatory than patients of race- discordant relationships. Therefore, a patient’s culture influences perception of care 45 provided, communication, compliance, and injury/illness assessment and management (Lipson, Dibble, & Minarik, 1996). This study found that there were no differences in level of cultural competency between newly certified ATCs and experienced ATCs. One could argue that new ATCs may score higher on cultural competency levels because most participants in this group would have graduated within the last five years and therefore went though a CAATE- accredited program. Conversely, some may argue more experienced ATCs would score higher than new ATCs due to experience level and opportunity of exposure to diverse situations. Most ATCs that completed the internship route to certification would be included in the experienced group. Although Sargent, Sedlak, and Martsolf (2005) state that cultural competence requires preparation through formal education, experienced ATCs that may have completed internship routes to certification performed comparably to new ATCs. This may also be due to the lack of formal cultural competence training through ATEPs. As stated prior, only 19.6% of participants reported taking a cultural competency or diversity course, and only 10.3% of participants reported athletic training specific cultural education. No significant differences in competency levels were found between the 11 NATA districts including international ATCs. Overall, respondents were evenly distributed by gender, race, and education throughout the districts, and therefore levels of competence did not vary significantly. Limitations There are several inherent limitations to this study. First, a comprehensive literature review identified no instruments specific to athletic training to measure cultural 46 competency levels. Therefore, the researcher modified an existing instrument that was developed to measure cultural competence among health care providers working in a variety of settings (Doorenbos, Schim, Benkert & Borse, 2005). Because of its generic nature, some of the questions may not have been easily applicable to ATCs. Also, there may have been more appropriate questions to assess cultural competency if the inventory was specific to athletic training. Because the CCA is not athletic training specific, baseline data may be slightly skewed. An athletic training specific instrument may provide a more reliable baseline level of cultural competency among ATCs. Second, although a large number of AT Cs responded to the survey (3,102), there was a relatively low response rate at 22.86%. Also, due to NATA membership rights, only 13,568 ATCs of 26,234 NATA student certified, international certified, and regular certified members received the inventory. The remaining ATCs elected not to receive the survey via email. There are also approximately 10,000 ATCs that are not members of the NATA and therefore not included in the sample. Because of the large number of participants needed to obtain the results, email addresses through the NATA was the most feasible way to assess cultural competence, however, this excluded non-NATA member ATCs. Therefore, this pool of participants may contain a higher or lower percentage of minority ATCs fi'om varying genders, years of experience, and districts which could have altered the results of this study. Further assessment of the remaining NATA members and non-NATA members would strengthen the credibility of the findings. Third, due to the topic of the research, some participants may have found cultural issues sensitive in nature and may have responded in a socially accepted fashion rather than the way they truly felt because the data was being analyzed. Also, certain 47 populations in the subject pool may have been more inclined to complete and return the inventory due to past experiences or interest in the research question. According to NATA membership statistics, 88.6% of ATCs are considered majority (White/Caucasian/European American) and 11.4% minority (NATA, 2007). However, 90.1% of participants considered themselves White/Caucasian/European American and the other 9.9% minority. Although they are similar in percentage, ideally respondents would mirror the NATA membership statistics so results can be generalized over all NATA members. Fourth, because the survey was administered via electronic mail through SurveyMonkey.com, some participants may have experienced technical difficulties when completing the inventory. Multiple respondents reported issues with advancing through the survey due to technical issues associated with the website. After communication with the website, complications were addressed and corrected, however this may have fi'ustrated participants resulting in them not completing the inventory. One hundred and fifty nine ATCs were excluded from the study due to incomplete surveys, and this may have been a contributing factor. These participants may have altered results of the study. However, due to the large participant pool needed to obtain data, electronic mail and intemet access were the most appropriate means for survey distribution. Despite these potential limitations, this research provided baseline data for levels of cultural competency among ATCs. Future Research Considerations This research supports the hypothesis that ATCs are culturally competent. However, ATCs view themselves as very competent, whereas actual scores report a level 48 of moderate competence. This baseline data can raise awareness to ATCs that the profession is not as culturally competent as self-reported. This will allow ATCs to be cognizant of opportunities to obtain further education on diversity issues and move from cultural awareness to cultural discussion. Now that baseline data has been collected in regards to cultural competency levels, future research can focus on the most appropriate method of educating ATCs on cultural issues among their athletes and patients. Maurer- Starks (2005) states that ATEPs must identify how they will prepare young professionals to provide health care services to diverse populations, which includes individuals from different races, ethnicities, religious affiliations, socioeconomic status, and sexual orientation. Research can also further examine the lack of racial diversity among both ATCs and ATSs. Although the profession of athletic training possesses a largely diverse cultural and experienced background, the large majority of ATCs are Caucasian. The athletes and patients ATCs treat do not reflect these statistics, and therefore may produce potential cultural barriers in health care. Further research should examine athletes’ and patients’ perceptions of ATCs in regards to cultural competence and health care provided. Results fiom these studies can also assist in the development of cultural competency education among ATCs. Further research should also assess the variations in level of cultural competency between various races and ethnicities on state and NATA district levels. Suggestions on how to educate ATCs on issues of diversity lead back to the education of ATCs and a call to educators to personally evaluate their respective knowledge bases, experiences, comfort levels, resources, and educational philosophies, 49 improving self-awareness and challenging the self to identify with personal history, race, ethnicity, and culture (Geisler, 2003). Only then can ATCs and ATSs alike gradually become more comfortable with taking part in communication and assessment regarding race, discrimination, and culture. Athletic training educators must increase awareness so students will be better prepared to work with the diverse populations they will encounter as health care professionals. Further research should focus on minority and international recruitment and retention into ATEPs to help diversify not only the profession of athletic training, but educational programs. This exposure allows students of all cultures to be immersed in a continual learning environment that athletic training educators can use to promote dialogue and exploration of diversity. Conclusion Becoming culturally competent is an ongoing, ever-changing process that is essential to providing the highest quality of care to the physically active population athletic trainers serve. Results of the current study indicated that ATCs are moderately culturally competent. Gender and race were found to have a significant impact on level of cultural competency. Years of certification and NATA district had no impact on level of cultural competency. Additionally, very few ATCs had ever participated in prior cultural diversity training specific to athletic training. The information from this study will provide a baseline for level of cultural competence among ATCs in their delivery of health care services. From here, educators can utilize and develop educational tools to assist young professionals in gaining knowledge on working with diverse individuals. Employers can develop profession- specific diversity training modules to enhance cultural awareness among staff. Athletes 50 and patients can be made aware that ATCs take cultural assessment into consideration while providing care. At the very least, this data will raise awareness among ATCs, reminding the profession that cultural issues arise and must be considered when treating patients. Optimal outcomes are achieved when health care practitioners possess more knowledge and respond with sensitivity to cultural issues (Ford, 2003). This is not simply treating everyone the same, but embracing the differences within and around various cultures and adapting treatment to accommodate every athlete’s or patient’s needs. ATCs have the unique opportunity to work with a largely diverse population and therefore must take advantage and grow from these experiences, continually utilizing them while providing care. With culturally competent care, ATCs can provide the optimal healing environment for those they treat, ultimately leading to greater patient outcomes and a more holistic level of athletic medicine. 51 APPENDIX A NATIONAL ATHLETIC TRAINERS’ ASSOCATION DISTRICT ORGANIZATION 52 District 1 (Eastern Athletic Trainers’ Associati_oa)_: Connecticut, Rhode Island, Massachusetts, Vermont, New Hampshire, Maine, and Quebec (combined with District 2). District 2 (Eastern Athletic Trainers’ Association): Pennsylvania, New Jersey, New York, and Delaware (combined with District 1). District 3 (Mid Atlantic Athletic Trainers’ Association): South Carolina, North Carolina, Virginia, West Virginia, District of Columbia, and Maryland. District 4 (Great Lakes Athletic Trainers’ AssociationL Michigan, Ohio, Illinois, Indiana, Wisconsin, Minnesota, Ontario, and Manitoba. District 5 (Mid American Athletic Trainers’ Association): North Dakota, South Dakota, Nebraska, Iowa, Kansas, Missouri, and Minnesota. District 6 (Southwest Athletic Trainers’ Associationk Texas and Arkansas. District 7 (Rocky Mountain Athletic Trainers’ Association): Arizona, Colorado, Utah, Wyoming, and New Mexico. District 8 (Far West Athletic Trainers’ Association): California, Nevada, and Hawaii. District 91Southeast Athletic Trainers’ Association): Kentucky, Tennessee, Louisiana, Mississippi, Alabama, Georgia, Florida, Puerto Rico and the Virgin Islands. District 10 (Northwest Athletic hainers’ Associationk Alaska, Idaho, Montana, Oregon, Washington, British Colombia, Alberta, and Saskatchewan (NATA, 2008). lntemational: All other countries or provinces not mentioned above where ATCs are employed. 53 v« Figure 1 National Athletic Trainers’ Association District Organization (N ATA, 2008) 54 APPENDIX B RECRUITMENT LETTER 55 RECRUITMENT LETTER Michigan State University is requesting your assistance with a research project investigating the level of cultural competence of certified athletic trainers in their delivery of health care. To assess cultural competence among certified athletic trainers, the Cultural Competency Assessment Inventory (CCA) will be distributed to ATCs throughout the nation. The CCA is a self-administered inventory consisting of 30 questions on a 7-point Likert scale that assesses the four constructs of culturally congruent care: cultural awareness, competence, diversity, and sensitivity. There are no identifying questions on this survey. Your responses will be returned to the survey website as anonymous data. You will indicate your voluntary agreement to participate in this research by completing and submitting the survey. If you choose to participate you may chose to not answer certain questions or withdraw at any time without consequence. You must be 18 or older to participate in this research study. Please click on the link below to begin the survey. The survey will take you approximately 10 minutes to complete. Your participation in this study is confidential. The results of this study may be published in a peer-reviewed journal; however any information that could identify you will not be included. This study has been approved by the human subjects committee at Michigan State University. Any questions about this study may be addressed to either myself or to the undergraduate Athletic Training Program Director, Dr. Tracey Covassin, Ph.D., ATC at 517-353-2010. Thank you for your participation and support. mew/WWW.surveymonkey.com/s.aspx?s_m=ZrCXmI8TD000UWFWFA870g 3d 3d Sincerely, Jeremy Marra ATC, CSCS Graduate Assistant Michigan State University marrajer@msu.edu Tracey Covassin Ph.D., ATC Undergraduate Athletic Training Program Director Michigan State University covassin@msu.edu 56 APPENDIX C CULTURAL COMPETENCE ASSESSMENT INVENTORY WITH DEMOGRAPHIC INFORMATION 57 CULTURAL COMPETENCE ASSESSMENT INVENTORY WITH DEMOGRAPHIC INFORMATION 1. In the past 12 months, which of the following racial/ethnic groups have you encountered among your athletes/patients and their families or within the health care environment or workplace? Mark 'X' for all that apply. Hispanic / Latino (including Mexican, Mexican American, Chicano, Puerto Rican, Cuban, other Spanish) White / Caucasian / European American Black / Afiican American / Negro American Indian / Alaska Native Asian (Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, or other Asian) Native Hawaiian / Pacific Islander Arab American / Middle eastern Other (please specify) 2. In your current environment, what percentage of the total population is made up of people from these racial/ethnic groups? Write in percents to add to 100%. Hispanic / Latino (including Mexican, Mexican American, Chicano, Puerto Rican, Cuban, other Spanish) White / Caucasian / European American Black / Afiican American / Negro American Indian / Alaska Native Asian (Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, or other Asian) Native Hawaiian / Pacific Islander Arab American / Middle eastern All other groups combined TOTAL = 100% 3. In the past 12 months, which of the following special population groups have you encountered among your athletes/patients and their families or within the health care environment or workplace? Mark 'X’ for all that apply. Mentally or emotionally Ill Physically Challenged / Disabled Homeless / Housing Insecure Substance Abusers / Alcoholics Gay, Lesbian, Bisexual, or Transgender Different religious/spiritual backgrounds Other (specify) 58 4. In your current environment, what percentage of the total population is made up of people from these racial/ethnic groups? Write in percents; may not total 100% Mentally or emotionally Ill Physically Challenged / Disabled Homeless / Housing Insecure Substance Abusers / Alcoholics Gay, Lesbian, Bisexual, or Transgender Different religious/ spiritual backgrounds All other groups combined 5. Overall, how competent do you feel working with people (including coworkers and athletes/patients) who are fi'om cultures different than your own? Very Competent Somewhat Competent Neither competent nor incompetent Somewhat Incompetent Very Incompetent For each of the following statements, put an "X' in the box that best describes how you feel about the statement. 6. Race is the most important factor in determining a person's culture. Strongly Agree Agree Somewhat Agree Neutral Somewhat Disagree Disagree Strongly Disagree No Opinion 7. People with a common cultural background think and act alike. Strongly Agree Agree Somewhat Agree Neutral Somewhat Disagree Disagree Strongly Disagree No Opinion 59 8. Many aspects of culture influence health and health care. Strongly Agree Agree Somewhat Agree Neutral Somewhat Disagree Disagree Strongly Disagree No Opinion 9. Aspects of cultural diversity need to be assessed for each individual, group/team, and organization. Strongly Agree Agree Somewhat Agree Neutral Somewhat Disagree Disagree Strongly Disagree No Opinion 10. If I know about an athlete’s/patient’s culture, I don't need to assess their personal preferences for health services. Strongly Agree Agree Somewhat Agree Neutral Somewhat Disagree Disagree Strongly Disagree No Opinion 11. Spirituality and religious beliefs are important aspects of many cultural groups. Strongly Agree Agree Somewhat Agree Neutral Somewhat Disagree Disagree Strongly Disagree No Opinion 60 12. Individual people may identify with more than one cultural group. Strongly Agree Agree Somewhat Agree Neutral Somewhat Disagree Disagree Strongly Disagree No Opinion 13. Language barriers are the only difficulties for recent immigrants to the United States. Strongly Agree Agree Somewhat Agree Neutral Somewhat Disagree Disagree Strongly Disagree No Opinion 14. I believe that everyone should be treated with respect no matter what their cultural heritage. Strongly Agree Agree Somewhat Agree Neutral Somewhat Disagree Disagree Strongly Disagree No Opinion 15. I understand that people from different cultures may define the concept of "health care" in different ways. Strongly Agree Agree Somewhat Agree Neutral Somewhat Disagree Disagree Strongly Disagree No Opinion 61 16. I think that knowing about different cultural groups helps direct my work with athletes/patients, their families, groups/teams, and organizations. Strongly Agree Agree Somewhat Agree Neutral Somewhat Disagree Disagree Strongly Disagree No Opinion For each of the following statements, put an "X' in the box that best describes how often you do the following: 17. I include cultural assessment when I do individual or organizational/team evaluations. Always Very Often Somewhat Often Often Sometimes Few times Never Not sure 18. I seek information on cultural needs when I identify new people in my work or school. Always Very Often Somewhat Often Often Sometimes Few times Never Not sure 19. I have resource books and other materials available to help me learn about people from different cultures. Always Very Often Somewhat Often Often Sometimes Few times Never Not sure 62 20. I use a variety of sources to learn about the cultural heritage of other people. Always Very Often Somewhat Often Often Sometimes Few times Never Not sure 21. I ask my athletes/patients to tell me about their own explanations of health & illness. Always Very Often Somewhat Often Often Sometimes Few times Never Not sure 22. I ask my athletes/patients to tell me about their expectations for health services. Always Very Often Somewhat Often Often Sometimes Few times Never Not sure 23. I avoid using generalizations to stereotype groups of people. Always Very Often Somewhat Often Often Sometimes Few times Never Not sure 63 24. I recognize potential barriers to service that might be encountered by different athletes/patients. Always Very Often Somewhat Often Often Sometimes Few times Never Not sure 25. I remove obstacles for athletes/patients of different cultures when I identify barriers to services. Always Very Often Somewhat Often Often Sometimes Few times Never Not sure 26. I remove obstacles for athletes/patients of different cultures when people identify barriers to me. Always Very Often Somewhat Often Often Sometimes Few times Never Not sure 27. I welcome feedback fi'om athletes/patients about how I relate to people fi'om different cultures. Always Very Often Somewhat Often Often Sometimes Few times Never Not sure 64 28. I find ways to adapt my services to individual and group/team cultural preferences. Always Very Often Somewhat Often Often Sometimes Few times Never Not sure 29. I document cultural assessments if I provide direct athlete/patient services. Always Very Often Somewhat Often Often Sometimes Few times Never Not sure Not sure 30. I document the adaptations I make with athletes/patients if I provide direct client services. Always Very Often Somewhat Often Often Sometimes Few times Never Not sure For the following information, please select the response that best represents your demographic information. What is your gender? Male Female 65 Using the categories below, what do you consider yourself? (Choose one or more) Hispanic/ Latino (including Mexican, Mexican American, Chicano, Puerto Rican, Cuban, other Spanish) White / Caucasian / European American Black / Afiican American / Negro American Indian / Alaska Native Asian (Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, or other Asian) Native Hawaiian / Pacific Islander Arab American / Middle eastern Other (please specify) How many years have you been a certified athletic trainer (ATC)? What is your age? In which NATA District do you currently work? District 1 District 2 District 3 District 4 District 5 District 6 District 7 District 8 District 9 District 10 lntemational (pleas specify) What is your primary employment setting (The following categories are the same as the NATA employment setting options)? College/University Clinic/Secondary School Clinic Only Secondary School Only Health/Fitness/Performance Enhancement Clinic/Club Hospital Professional Industrial/Occupational Corporate Amateur/Recreational/Youth Sports Military/Law Enforcement/Governmental Other (please specify) 66 What is your highest level of education completed? Bachelors Masters Doctorate For your athletic training education, did you complete an accredited/approved curriculum or an internship? . Accredited/approved curriculum Internship Have you ever participated in cultural diversity training? Yes No If you have had prior diversity training, which option below best describes it? 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