Assessment of Perceived Diversity and Inclusivity of Athletic Training Textbooks

• Athletic training textbooks can contribute to a more inclusive education for athletic training programs through diverse representation of gender, race/ethnicity, age, body size, and body expression.

• Athletic training educational textbooks included on the Board of Certification exam reference list lack inclusive images that reflect the diversity of patient and clinician population.

• A lack of diversity in educational images may negatively impact student preparation to evaluate and treat people of different ages, body sizes, or skin tones.

Diversity, equity, and inclusion (DEI) is a conceptual framework used to describe an inclusive environment recognizing the contributions and backgrounds of all, regardless of nationality, ethnicity, race, religion, age, sex, marital status, gender identity and expression, sexual orientation, or ability.¹  According to the 2020 US Census, White non-Hispanic individuals make up 57.8% of the population, which is a decrease from 63.7% in 2010. In 2020 the Hispanic or Latino population was the second largest racial/ethnic group at 18.7%, and the Black or African American non-Hispanic population was the third largest at 12.1%.²  As of 2020, only 47.3% of the population under age 18 identified as White non-Hispanic,²  and the US Census projects that the population aged 18 to 29 will become “minority White” in 2027 and the entire US population in 2045.³  Health care providers need to be aware of how this shift in patient population can affect the ability to provide quality patient care to a diverse population.⁴ 

The National Athletic Trainers’ Association (NATA) was founded by 200 White men in 1950, before Brown v Board of Education (1954) and the Civil Rights Act (1964). As stated in a recent Journal of Athletic Training editorial, the foundation and mission of the profession were cultivated without the influence of underrepresented groups, and by the time the Board of Certification (BOC) and the Commission on Accreditation of Athletic Training Education (CAATE) were incorporated, the profession’s cultural framework was already well established.⁵  It was not until 1986 that the NATA directly focused on issues related to diversity in the profession. The Minority Athletic Trainers’ Committee was created in 1986 and restructured in 1991 before transforming into the Ethnic Minority Advisory Council and finally the Ethnic Diversity Advisory Committee (EDAC) in 1999.⁶  The NATA states its commitment to diversity, equity, inclusion, and access as part of its mission statement: to promote unparalleled delivery of athletic training services amid ever-growing global and diverse populations, and recognize that increasing the racial and ethnic diversity of the health care workforce is essential for culturally competent care and to impact health outcomes.⁷  However, the athletic training profession is not as diverse as the patient population it serves.⁴  Although the athletic training profession continues to expand its reaches to diverse patient populations, the demographics within the profession (based on NATA membership) remain relatively unchanged. A review of NATA membership data from 1997, 2015, and 2018, as well as 2022–2023 BOC data on certified athletic trainers, shows that, despite a 2-fold increase in membership, the membership remains approximately 80% White (Table 1).^4,8,9  This disparity between provider and patient demographics emphasizes the need for cultural competency in order to provide the highest quality of patient care.

Diversity within patient populations is not limited to race and ethnicity, but should also consider gender identity, sexual orientation, and ability status.⁴  Adopting diverse perspectives within the athletic training profession is increasingly important, and athletic training education should foster representation all patient populations within educational materials.^10–12  Inclusive teaching practices include the use of learning materials that include diverse examples in course content.¹³  It has been recommended that cultural competency is enhanced by gaining exposure to patients of varying ethnicities.^4,14–17  Textbooks are commonly used as part of athletic training education and as preparation for the BOC examination. Across the health professions there is lack of diversity in images of both patients and clinicians within educational resources (ie, textbooks, journal articles).^18–25  The majority of images represent persons with light skin tone assumed to be White/Caucasian, young or middle-aged adults of average weight, with no “unusual” body expression (ie, tattoo, unusual piercings, religious clothing, or head covering).^18–25 

Athletic training accreditation requires educators to prepare professional students within a culturally competent, patient-centered approach; however, to our knowledge there is no published literature highlighting the representation of racial and ethnic demographics of clinicians or patients within athletic training educational resources.^10,26  The purpose of this study is therefore to investigate the diversity and individual expression visible in photographs and illustrations of patients and clinicians within textbooks commonly used in athletic training education.

This study used a cross-sectional survey design to collect data. Athletic training and health care textbooks listed on the 2023–2024 BOC exam reference list were eligible for inclusion in this study; this list was the most current list available at the time of data collection.²⁷  The BOC exam reference list represents the materials used to support exam items as determined by the BOC Exam Development Committee. Twenty percent of the 76 texts on this list were randomly selected for inclusion using a random numbers table (n = 15; Table 2). For these 15 texts, 20% of chapters were selected for examination, again using a random numbers table. For example, a textbook with 20 chapters would have 4 chapters randomly selected. If a chapter had no images where patient and/or clinician features were observable, a different chapter from that textbook was randomly selected. Included textbooks represented each of the 5 domains of practice as outlined by the BOC Practice Analysis, 8th edition.²⁶  A priori sample size analysis indicated the desired sample size was 231 images (calculated using G*Power; α = .05, power = .80, effect size = 0.25).

An online survey was created in Qualtrics; survey criteria were modeled after criteria used in cultural competence research performed by the doctor of physical therapy program at our institution.²⁵  Some modifications were made to represent the more diverse clinical practice settings and patient populations in athletic training (athlete or nonathlete category was added, setting category was added). Face and content validity of the modified survey were established by a panel of 3 athletic training educators with more than 50 combined years of experience in education and experience as textbook authors. The survey prompted each reviewer to identify who reviewed the text, which textbook they were reviewing, and the figure number identifying the image. If there was more than 1 person in the image each person was coded separately, and researchers entered an identifier for the person within the image they were coding (eg, “person on the left”). The survey consisted of 9 sections categorized by image type, setting, person, assumed skin tone, assumed race or ethnicity, assumed gender, body size, age grouping, and body expression (Table 3). Images were excluded from coding if they depicted a human body for anatomical purposes only (eg, an opened cadaver) or if no aspect of the person’s body could be viewed. All reviewers completed coding individually and were blinded to other reviewers’ codes.

Five faculty members and 2 students enrolled in a single CAATE-accredited professional Master of Science in Athletic Training program were recruited as coders. As image coding is a subjective process, all coders participated in a coding training session conducted by the lead author. As part of this training, each subcategory (Table 3) was defined and images from textbook chapters not randomly selected for inclusion were displayed. Coders were instructed to mark other or unable to assess if it was not clear which category subtype was represented in the image. Skin tone subcategories were based on the Fitzpatrick scale (light: types I–III, medium: types IV–V, dark: type VI), which has often been used to classify pigmentation in patient populations.²⁸  The Fitzpatrick scale has been used in previous studies on image diversity,^19,23  and was selected over the Taylor Hyperpigmentation Scale due to fewer categories. An image of the Fitzpatrick scale was also shared with coders. Each of the sample images was coded individually by each potential coder and coding was reviewed by the lead author. All coders were consistent in coding the sample images.

After the training session, 2 coders independently coded each textbook image that included at least 1 person, based on criteria outlined in Table 3. Coders 2 through 6 were randomly assigned chapters from the textbook list; the number of images in each chapter was unknown at the time of chapter assignment (Table 2). A third independent coder (coder 7, the lead author) confirmed that all image coding was consistent between the 2 coders. If there was inconsistency, the coders were asked to review the image to ensure their code was entered correctly. If there was still inconsistency the 3 individuals consulted and reviewed the image together to agree on a code. If agreement could not be reached the image category was coded as unable to assess.

Frequency statistics were generated for each characteristic included in Table 3 and χ² goodness-of-fit tests were performed to determine if frequencies were significantly different. The expected frequency counts for all categories were >5, indicating the study was appropriately powered. Included textbooks were divided into 5 categories based on the 5 domains included in the BOC Practice Analysis (8th ed), and χ² tests of independence were performed to determine if frequencies were significantly different based on domain. Chi-square tests of independence were also performed to determine if frequencies were significantly different based on person type (athlete, nonathlete, clinician).

Images were coded from 66 chapters across 15 textbooks (Table 2). A total of 1667 persons were assessed from 1190 images. There were 1318 photographs, of which 1244 (94%) were color and 74 (6%) were black and white, and a total of 342 illustrations, of which 141 (41%) were color and 201 (59%) were black and white or blue and white. The overall breakdown of diversity in images is included in Table 3. Images primarily depicted persons who were of light skin tone (86%) and assumed to be White or Caucasian (86%), young adults (75%) of average weight (95%), with little diversity in body expression (95% none of the above). Persons who were not obviously identified as athlete were most often depicted (41%) and the majority of settings were clinic based (72%). Chi-square goodness of fit for each of these characteristics was significant at P < .001, indicating that the majority category frequencies were significantly different than would be expected by chance. Visual inspection of the data indicated that the most recent textbook included in this study, published by Kahanov and Payne in 2022, contained the most diverse images.

Image diversity breakdown by person depicted (Table 4) and textbook domain (Table 5) was also assessed. Chi-square tests of independence were performed with person or textbook domain as the presumed independent variable, and subject characteristics as the perceived dependent variables. All χ² statistics were significant at P < .05 (Tables 4 and 5). There was greater representation of assumed race/skin tone in textbooks categorized under Domain V: Healthcare Administration and Professional Responsibility, suggesting that the content of the domain may demand more heterogeneous images.

This study investigated the diversity and individual expression of patients and clinicians in images found in commonly used athletic training textbooks. The findings of this study support existing literature in the fields of physical therapy, nursing, dermatology, and medicine, in that the majority of textbook images represented persons with light skin tone assumed to be White/Caucasian, young or middle-aged adults of average weight, with no “unique” body expression (eg, tattoo, unusual piercings, religious clothing or head covering).^{18–20,23–25}  This lack of diversity in textbook images suggests that underrepresentation of persons of diverse skin tones and body expression is present within the educational resources of most health care professions, including athletic training.

It was reported in a previous study with physical therapy students that students may have difficulty relating to the profession if they do not see themselves represented as health care professionals within the educational material.¹⁶  This feeling of not belonging has the potential to limit the number of people from underrepresented groups who enter the profession.^29,30  Without diverse students within the athletic training education system, the profession lacks a workforce representative of the populations it serves.³¹  Despite various initiatives by the NATA to increase the diversity of the profession, including the development of the EDAC, demographics of certified athletic trainers remain approximately 80% White.⁹  This is similar to physical therapists (76% White), occupational therapists (81.6% White), speech-language pathologists (83.2% White), and physician assistants (75.6% White), but higher than physicians (63.8% White) as of 2022.^32–36  It has been suggested that the NATA review the impact the EDAC should have on the larger population, and that the EDAC should act and advise the NATA on how to tackle diversity within itself.⁵ 

It is also important for the diverse patient populations who receive athletic training services to be represented in educational resources. If students are not exposed to diverse populations in their education, they may be poorly prepared to evaluate and treat people of different ages, body sizes, or skin tones.^18,20,25  This lack of diversity in educational materials also impacts current clinicians who use textbooks to assist in evaluation of patients. In addition to diverse characteristics of the patient, diverse clinical practice settings should also be represented. The settings most often depicted in our study were clinic (72%) and athletic venue (21%); however, the athletic training profession has expanded to provide services in occupational health, industrial medicine, military, performing arts, and other diverse settings.^4,8,37  These settings should be represented in educational materials so athletic training students are exposed to various opportunities available to them upon entering the workforce. Similarly, the majority age group represented in these images was young adult (75%), with children, adolescents, and older adult categories each making up 2% or less of all images. Textbook images should represent the broad range of age groups to whom athletic trainers provide services to better demonstrate the scope of our professional competence. It is important for athletic trainers to be exposed to multicultural perspectives and to be empowered to maximize their capacity to deliver high-quality patient care and education.³⁸ 

Athletic training educators are tasked with influencing the profession through the production of competent athletic trainers; however, they can also influence the profession through their choices in learning materials. Educators can and should seek out textbooks with diverse images of patients, clinicians, and clinical settings. When published materials are not available, educators should consider creating their own learning materials that feature patient populations and clinical settings that are underrepresented in published educational materials. These types of diverse educational materials may better prepare students to serve underrepresented populations.^20,39  The NATA as the member organization, the BOC as the credentialing organization, and the CAATE as the accreditation organization should truly work together as a strategic alliance towards alignment of educational and promotional materials with the diversity of the athletic training profession.

Our study found greater representation of assumed race/skin tone in textbooks categorized under Domain V: Healthcare Administration and Professional Responsibility, suggesting that the content of the textbook may demand more heterogeneous images. Additionally, the most recent textbook included in this study, authored by Kahanov and Payne in 2022, contained some of the most diverse images, which may suggest increasing awareness of the need for image diversity by textbook authors. The BOC Exam Development Committee can influence the profession through the materials they choose to place on the BOC exam reference list, and by using the most current version of textbooks to develop exam questions. Because athletic training programs often require or recommend textbooks from this list, being removed from the list due to lack of diverse images could send a powerful message to publishers about the need for greater inclusion of underrepresented populations and settings in textbook images. Previous researchers have suggested that publishers collaborate with DEI experts and offices to increase the diversity of images included in textbooks; it is therefore recommended that authors and publishers of athletic training–related textbooks increase such collaborative efforts, and that they follow the NATA Style Guide for Cultural Competency in NATA Projects.^25,40 

A limitation of this study is that only 20% of textbooks randomly selected from the BOC exam reference list as of March 2023 were included and only 20% of textbook chapter images were coded. Although this is consistent with previous research, the sample may not be representative of all athletic training texts and images. Additionally, since the time of data collection newer editions of some textbooks have been published, which may have increased image diversity. Finally, only face and content validity were established for the survey used in this study. Future research should include a larger sample of textbooks and/or evaluate textbooks not on the BOC exam reference list that are frequently used by athletic training programs. It would also be of interest to investigate how images are selected for textbooks, and how much autonomy authors themselves have as compared with publishers in creating or selecting images. Finally, future researchers may consider exploring the decision-making processes of athletic training educators when selecting textbooks and whether there is consideration related to image diversity.

The current study highlights disparities in health care education. The overarching DEI framework aims to promote fairness and equal participation of all people, especially those who have been historically underrepresented or discriminated against because of their background, identity, or ability level.⁴¹  Institutions offering degrees in health care professions should seek to extend the framework of diversity and inclusion into their educational models. Underrepresentation of persons with diverse skin tones and of various ages within athletic training textbooks and educational images is a concern, as it may hinder the development of culturally competent clinicians and contribute to disparities in medical diagnoses across different racial groups. Additionally, the lack of diversity in clinical practice settings may limit the number of people seeking to pursue work within less traditional settings. The act of learning about diverse patient populations and differences in their clinical presentation may allow athletic training programs to build more inclusive learning environments and graduate professionals who perform more culturally competent patient care.