International topics in athletic training are gaining recognition. Particularly interesting are opportunities for athletic training students to gain international experiences and develop cultural competence through study abroad. However, little is known about current international experience opportunities for these students.
To identify international experience opportunities for athletic training students, investigate student and faculty participation, and describe characteristics of institutions and programs offering such experiences.
All directors of Commission on Accreditation of Athletic Training Education–accredited professional athletic training programs were recruited. The response rate was 41.9% (163/389).
An e-mail soliciting participation was sent in January 2019. The online survey had 4 sections: (1) questions about athletic training–related international experiences, (2) questions about discipline-related international experiences, (3) questions about athletic training faculty or student participation, and (4) demographic questions about the program or institution. Data were analyzed descriptively. The characteristics of programs offering athletic training–related international experiences were compared with programs offering discipline-related international experiences using χ2 tests for degree level, institution type, and athletic division.
Twenty-nine programs (17.8%) offered athletic training–related international experiences and 68 programs (41.7%) offered discipline-related experiences. Private universities were more likely to offer an athletic training–related experience, and public universities more likely to offer a discipline-related experience (χ2 = 4.197, df = 1, P = .04). There were no other differences between institution types, program degree levels, or athletic divisions (all P > .05). Some programs reported no recent athletic training student (44%) or athletic training faculty (58%) participation in any international experience.
A minority of programs currently offer either athletic training–related or discipline-related international experiences. Characteristics of available programs vary widely. To keep pace with professional globalization, future work should identify ways to develop international experiences.
A minority of programs offer either athletic training–related (18%) or discipline-related (42%) international experiences to athletic training students.
Characteristics of international experiences vary widely in format, content focus, and activities within the host country.
Opportunities exist for developing new international experiences for athletic training students.
International topics in athletic training (also known as athletic therapy in some countries) have been gaining recognition in athletic training education in recent years, as evidenced by a recent special edition of the Athletic Training Education Journal (2019;14) dedicated entirely to global education in athletic training. Many initiatives are occurring within athletic training that have placed the profession on a global stage. Just a few examples include cultural awareness campaigns, international speaker exchange programs, collaboration with international partners, and study abroad programs.1
As athletic training continues to globalize, the expectations of students for international experiences to be part of their education also increase.1 Numerous benefits come from international experiences that are offered through service learning, volunteerism, internships (for credit or noncredit) or study abroad opportunities.2 International experiences are important to develop a broader and more global view of the world,3 develop cross-cultural skills and knowledge,4 operate in a foreign environment, and develop cultural competence.5
Developing intercultural competencies and thereby globally minded individuals is a priority of US higher education institutions.6 A failure to develop students' ability to function in the increasingly globalized world can lead to a lack of effective communication due to cultural misunderstandings and unintentional biases.7 This affects athletic training because, as in most healthcare professions, a healthcare provider–to–patient population diversity gap exists.8 In one attempt to navigate these challenges, the accreditor of US athletic training programs, the Commission on Accreditation of Athletic Training Education (CAATE), placed cultural competence within the 2020 CAATE Standards (eg, Standards 17, 56, 57, and 60).9 Cultural competency is also a priority in international peer professions, such as accredited athletic therapy programs in Canada and Ireland.
Teaching athletic training students the knowledge and skills needed to be culturally competent is both important and challenging. It has been shown that transitioning cultural competence into clinical practice is difficult for students.10 While cultural competence can be developed locally, one powerful way of developing this competency is to offer students the opportunity to embrace a new culture by providing international experiences. Past literature has detailed both challenges and opportunities with respect to offering international experiences curated to athletic training students in countries such as Japan, Nicaragua, and Australia.11–14 These resources offer valuable information to athletic training educators interested in creating their own study abroad. They also highlight that international experiences vary widely, from trips catered to a disciplinary/interprofessional audience to trips exclusive to athletic training students, including direct patient encounters or clinical experiences.11–14
While detailed accounts exist of individual study abroad programs,11–14 to date there has only been 1 nationwide study of international experience opportunities for athletic training students and faculty.15 This investigation was conducted by the National Athletic Trainers' Association (NATA) International Committee (IC) and shared data from the 2016 to 2017 CAATE mandatory national report (thus providing data for the entire population of CAATE-accredited athletic training programs rather than a sample). The data revealed that only 10.6% (n = 42) of programs offered an international experience specific to athletic training, although 84.4% (n = 335) offered any international experience open to athletic training students.15 Considering the low numbers of international experiences specific to athletic training that were reported, there is a clear opportunity for development in this area. This investigation had several limitations, primarily its limited question set (only 4 brief questions) and lack of standardized definitions of terms. A recommendation was that future research on this topic be conducted to identify strengths, challenges, and priorities for the development of international experiences for athletic training students.
In light of these limitations and recommendations for future research, the NATA IC decided to conduct a more in-depth survey of international experience opportunities in athletic training to better support existing programs, identify trends and gaps, and set future priorities regarding support and development of international experiences. The NATA IC set out to identify which athletic training programs offer international experiences and whether those were directly related to athletic training or more related to broader disciplines (eg, health science, kinesiology), who participates in these experiences (eg, among athletic training faculty and students), and what kinds of institutions and programs offer such experiences (eg, private versus public, athletic division, degree level).
All program directors of CAATE-accredited professional athletic training programs were recruited for participation in this study (n = 389). The list of accredited programs and program directors was taken from the CAATE Web site in December 2018 and included all professional programs at the undergraduate or graduate level. Participants were recruited via e-mail in January and February 2019.
This study was approved by Whitworth University Institutional Review Board. An e-mail soliciting participation in this research survey was sent to the program director on record at 389 CAATE-accredited professional athletic training programs in January 2019. After 11 days, a first reminder was sent. Then a final reminder was sent after an additional 15 days. Data collection was closed 30 days after opening. Two $100 gift cards were offered as a participation incentive to randomly selected participants.
Data were collected online using Qualtrics Survey Software (Qualtrics LLC, Provo, UT). After giving informed consent, program directors (or their designee) were asked to complete a survey regarding international experiences connected to their athletic training program or home department. The completion of all survey items took approximately 6 minutes.
The survey started by providing 3 relevant working definitions (“international experience,” “athletic training–related experiences,” and “discipline-related experiences”) to ensure that participants understood the intended meaning of survey items. An international experience was defined as “a course, service project, or international exchange involving travel abroad.” International experiences could be related to athletic training or related to a broader discipline. Athletic training–related experiences were defined as “an international experience exclusive to athletic training students (professional or preprofessional), athletic training content, or the athletic training profession.” Discipline-related experiences were defined as “an international experience related to broader disciplines such as, but not limited to, healthcare, exercise science, sports medicine.” There were 4 main sections of the survey: (1) questions related to athletic training–related international experiences, (2) questions related to discipline-related international experiences, (3) questions related to athletic training faculty or student participation in international experiences, and (4) demographic questions about the program or institution. The survey was adjusted based on participant responses (eg, if a participant indicated that his or her institution did not have an athletic training–related international experience, those questions were skipped). Thus, the number of survey items ranged from 8 to 15, depending on participant responses. The survey was developed by 2 members of the NATA IC and approved by the entire committee before use in this research.
Survey results were exported from Qualtrics into Excel (Microsoft, Redmond, WA) and imported into SPSS Statistics version 23 (IBM, Armonk, New York). Questions about the number, format, academic focus, and activities of international experiences were analyzed descriptively as frequency and percentage. The characteristics of programs offering athletic training–related international experiences were compared with programs offering discipline-related international experiences using χ2 tests for degree level, institution type, and athletic division. The same comparisons were made for institutions offering discipline-related international experiences. Additionally, the characteristics of institutions offering athletic training–related international experiences were compared with institutions offering discipline-related international experience using χ2 tests for degree level, institution type, and athletic division. All other data are presented descriptively.
A total of 166 survey responses were recorded. Three responses were from the same school and gave conflicting answers; thus all 3 were excluded. The final total of 163 responses represents a response rate of 41.9% (163/389). Demographic data for all programs are available in Table 1.
Athletic Training–Related International Experiences
There were 29 programs (17.8%) with athletic training–related international experiences and 134 programs (82.2%) without these experiences. Demographic data for the programs with athletic training–related international experiences are available in Table 1. There was no significant difference in the frequency of offering an athletic training–related international experience between institution types (χ2 = 2.786, df = 1, P = .095), program degree levels (χ2 = 6.565, df = 4, P = .161), or athletic division (χ2 = 9.002, df = 4, P = .061). Interestingly, there was a significant difference between institution types offering athletic training–related versus discipline-related international experiences (χ2 = 4.197, df = 1, P = .040). Specifically, private universities were more likely to offer an athletic training–related international experience, and public universities more likely to offer a discipline-related international experience. There were no differences between institutions offering athletic training–related versus discipline-related international experiences in program degree level (χ2 = 7.137, df = 4, P = .129) or athletic division (χ2 = 4.262, df = 4, P = .372).
The majority of athletic training–related international experiences are college/university courses, although other formats such as service projects and international travel with teams are also reported (Figure 1). The 3 most common types of activities during athletic training–related international experiences are tours of medical facilities and tours of athletic training facilities, followed by interprofessional educational activities (Figure 2).
Discipline-Related International Experiences
There were 68 programs (41.7%) with discipline-related international experiences and 90 programs (55.2%) without these experiences. Demographic data for the programs with discipline-related international experiences are available in Table 1. There was no significant difference in the frequency of offering a discipline-related international experience between institution types (χ2 = 0.709, df = 1, P = .400), program degree levels (χ2 = 3.010, df = 4, P = .556), or athletic division (χ2 = 6.499, df = 4, P = .165). The majority of these experiences are college/university courses, although other formats such as service projects and international exchanges are also used (Figure 3). The most common disciplinary focus of these experiences is sports science, then healthcare and public/global health (Figure 4).
Athletic Training Faculty Participation in International Experiences
The program was asked about faculty participation in any international experiences within the last 2 years. Ninety-four programs (58%) reported that no athletic training faculty led an international experience during this time period. Fifty-two (32%) programs reported that an athletic training faculty member led an athletic training–related international experience, and 38 (23%) programs reported than an athletic training faculty member led a discipline-related international experience (some of the programs reported participation in both categories; thus percentages do not equal 100%).
Athletic Training Student Participation in International Experiences
The program was asked about athletic training student participation in any international experiences within the last 2 years, including both preprofessional and professional students. Seventy-two programs (44%) reported that no athletic training students participated in an international experience during this time period. Professional students participated at a higher rate than preprofessional students, with 37 (23%) programs reporting professional student participation in athletic training–related international experiences and 62 (38%) programs reporting professional student participation in discipline-related international experiences. In contrast, 16 (10%) programs reported preprofessional student participation in athletic training–related international experiences and 38 (23%) programs reported preprofessional student participation in discipline-related international experiences. Some programs reported student participation in more than 1 category; thus, percentages do not equal 100%.
The purpose of this research survey was to document current international experience opportunities and participation in athletic training programs. This survey was developed and sponsored by the NATA IC in alignment with its mission, which includes supporting and developing international experiences related to athletic training for NATA members.
Frequency of International Experience Opportunities
Past research on international experiences in athletic training is limited. In a recent commentary, Wright15 shared survey data collected from accredited athletic training programs in the 2016 to 2017 academic year. While a helpful addition to sparse literature, this data was limited in scope and clarity as the questions used terms without standardized definitions (which could have resulted in varying individual interpretations). The greatest strength of the study was that it captured data from the entire population of accredited athletic training programs (410 at the time) as the data was part of a mandatory report. The current research shows that a higher percentage of programs offer an athletic training–related international experience (17.8%, n = 29) or discipline-related international experience (41.7%, n = 68) compared with past research (10.2%, n = 42 athletic training programs offered an international experience). Since the 2016 to 2017 survey did not clearly define terms, it is unclear if the 42 international experiences included athletic training–related experiences, discipline-related experiences, or both. Thus, it is impossible to tell whether the absolute number of opportunities has increased (97 total experiences in 2019 versus 42 in 2016–2017) or decreased (29 athletic training–related experiences in 2019 versus 42 in 2016–2017). However, anecdotally the authors are aware of several peers who are working to develop new athletic training–related international experiences for their program, making it seem likely that the number of opportunities is on the rise. Aligning with this observation, the current survey reported that 42% of programs had at least 1 athletic training faculty member participate in any international program, compared with past research, which showed that 23.4% of programs had at least 1 athletic training faculty member participate. Athletic training student participation in any international experience was also higher in the current survey (56%) than in past research (40.2%). As athletic training programs prepare future clinicians to practice in an increasingly diverse and globalized world, international experiences can be a powerful learning tool.5,13 Increased offerings and participation are positive indicators.
Characteristics of International Experience Opportunities
We found that private universities were more likely to offer an athletic training–related international experience, and public universities were more likely to offer a discipline-related international experience. According to a 2017 report put forth by the American Council on Education (ACE) on mapping internationalization on US campuses,16 47% of institutions included internationalization among the top 5 priorities in their strategic plans, and nearly half (49%) of institutional mission statements included reference to international or global activities. A sector snapshot identified that the primary difference between private and public institutions was funding. Private institutions are more likely to have fundraising campaigns to support internationalization, provide scholarships, have initiatives to internationalize the undergraduate curriculum, and offer faculty development programs and funding opportunities to travel abroad. Private institutions are more likely to require all students to take a foreign language, receive federal and/or state funding for internationalization activities, provide English as a second language (ESL) support, and offer workshops for faculty to internationalize the curriculum. This aligns with our study's findings that more private institutions offer athletic training–related experiences, possibly due to the financial means and institutional support to offer such experiences. Understanding opportunities and challenges associated with developing international experience opportunities at public versus private universities may help both students and faculty select institutions that fit their goals, as well as help those already in a given environment to navigate it more aptly.
It should also be noted that while we found differences based on institution type (public versus private), there may be additional underlying variables related to the individual athletic training faculty at these institutions that we did not track in the current study. Specifically, if a faculty member has numerous and/or strong international connections, he or she might be more likely to successfully develop an international experience.
It is refreshing to see both graduate and undergraduate programs offer international experiences; this may be a testament to the globalization of athletic training. In the United States, professional education with regard to becoming an athletic trainer is evolving. By 2022, all programs must be at the graduate level. We were impressed at the number of graduate athletic training–related international experiences already offered. It is also not that surprising that the graduate programs offer more international athletic training–related experiences because of the focus on athletic training education, rather than combining institutional core curriculum courses with athletic training courses as seen in the undergraduate programs. Additionally, from 2020 onward, the new CAATE Accreditation Standards must be implemented. Although the standards do not require international travel, standard 16 requires a minimum of one 4-week immersive experience for every student. It is possible that students could meet this requirement through international clinical experiences with athletic trainers practicing abroad.
Currently, there are Board of Certification (BOC)-certified athletic trainers clinically practicing in countries such as Canada, China, Ireland, and Japan. A list of all countries where BOC-certified athletic trainers receive mail is provided in Table 2. However, it is unknown how many of these individuals are actively practicing as athletic trainers. It will be interesting to monitor if the number of international clinical rotations increases after the full adoption of the CAATE 2020 Standards. Future research should explore clinical experience opportunities in different countries where BOC-certified athletic trainers practice. Certainly, jurisdictional considerations, regulation of the athletic training profession in the host country, and immigration policies will play a role in the development of international opportunities.
Athletic Training Faculty and Student Participation
A minority of programs (42%) reported athletic training faculty involvement in leading an international experience, and just barely over half of programs (56%) reported student participation. Both student and faculty participation rates in the current study are higher than in previous reports.15 While the availability of convenient opportunities is likely 1 factor influencing participation, a variety of other factors may encourage or discourage participation. Understanding these factors may be helpful as the profession prepares current and future athletic trainers to move forward into an increasingly global environment. In 1 study17 , variance in students' decisions to study abroad was best explained by curricular/career issues (including whether it was a degree requirement or career advancement opportunity; 15% of variance), followed by fear of the unknown (13% of variance), and financial considerations (9% of variance). Lifestyle, social obligations, and prior travel experience also contributed but to a lesser extent.17 Most students indicate a preference for study abroad in an English-speaking country, and indicate that regardless of parental income level they would need financial aid to support study abroad.18 Before traveling, students may be anxious about language barriers and cultural differences, as well as leaving behind friends and family.17,18 Yet students who participate in study abroad experiences often reflect positively about learning from the host culture and expanding their comfort zone. Based on this prior research, one of the strongest incentives to increase participation in athletic training international experiences would be to make it an option to fulfill a curricular requirement and/or make clear the value of the international experience for future career advancement opportunities. Strategies to lessen fear of the unknown (eg, education, faculty-led short-term trips) may also have a high impact.
As with students, a confluence of factors may influence athletic training faculty decisions to lead a study abroad trip, including (but not limited to) family commitments and support, perceived value of study abroad leadership and fit with career advancement requirements (eg, tenure and promotion), experience or support with international travel planning, and available connections/network within a potential host country.19,20 These factors are complex and interrelated. If the athletic training profession aims to significantly advance study abroad opportunities for students, factors affecting athletic training faculty involvement will also need to be addressed.
When developing new international opportunities, or when revising current programs, it is important to pay careful to issues the host country or region is facing. Opportunities should provide a comparative approach to enhance discipline-specific learning.21 We cannot simply take what we do in the United States and teach in the same way, just in a different country. Typically, the content and purpose of international experiences are determined by individual faculty members. When planning they need to pay close attention to intercultural learning and disciplinary content simultaneously. One potential pitfall to faculty-led study abroad experiences is the potential to socialize solely within the travel group, rather than engaging in authentic intercultural interactions with the host culture. Only through conscious awareness can we avoid this pitfall.21 One summary of the literature in this area concluded that faculty leading such international opportunities must explicitly incorporate intercultural learning and intentionally engage students in cross-cultural learning opportunities to effectively develop global competence.21 Those involved in future international experience in athletic training should keep these recommendations in mind.
We hope to see the number of athletic training-related international experiences rise in the coming decades. However, the immediate future of international experiences in athletic training education is facing challenges due to the current global pandemic caused by the COVID-19 virus. With travel bans at both the governmental and university levels, many study abroad programs have already been cancelled. Currently, concerns about participant safety are foremost, but even as safety concerns abate the financial impact of the pandemic may raise economic barriers for universities and/or students. The impact of the pandemic on international education will likely be felt most severely in the next 1 to 2 years, with a gradual reopening of these impactful experiences. While plans to incorporate international experiences may by temporarily on hold, long term strategic planning could lay the groundwork for success once the current pandemic is resolved. We encourage this strategic planning to include international experiences that develop, promote, and/or investigate how athletic trainers can address critical health care needs globally.
We believe that in comparison with past studies, the clearly defined terms in the current research led to more accurate reporting. Unfortunately, it is possible that selection bias influenced the current results, with programs offering international experiences more likely to complete the survey. This possibility limits the comparison with past data (which represented the entire population).
The goal of this survey was to gain insight to better support existing programs, identify trends and gaps, and set future priorities regarding support and development of international experiences. From the results, trends in participation rates, frequency of international experience offerings, and characteristics of international experience opportunities are available for comparison. Factors such as institution type, program degree level, and athletic division had minimal to no impact on the frequency of international experience opportunities. Individual and organizational stakeholders in the internationalization of athletic training and development of cultural competency in athletic training students should use this data to continue to address challenges and opportunities in strengthening international experience opportunities for athletic trainers.
We would like to thank the NATA IC for funding this study.