Athletic Training Students’ Knowledge and Awareness of Diversity and Inclusion to Provide Culturally Competent Care

• Athletic training students demonstrated increased levels of cultural competence when comparing pre- and post-Cultural Competence Assessment Inventory.

• Full or partial completion of diversity education showed increased cultural behavior scores among all participants.

• Education should be emphasized in Athletic Training Programs to promote culturally congruent practice, reinforce patient-centered care, and decrease health disparities.

Expanding demographics within American society have created an evolving need for all health care providers to be equipped to care for patients representing different cultural groups. In observing the 2010 US Census Bureau, 63% of the population was White, and 37% belonged to a racial and ethnic minority group such as Black or African American, Hispanic, American Indian or Alaska Native, Asian, or Hawaiian or Other Pacific Islander.¹  Since then, the 2021 US Census Bureau has shown 59% of the population was White, and 41% belonged to a racial and ethnic minority group.²  The US Census projects by 2043, racial and ethnic populations will comprise more than 50% of all Americans.³  American society has also shown an increase in diversity within language, religion, gender, sex, ability, and access to technology.⁴  The increase in diversity has already produced a multitude of cultural gaps including quality of care and economic stability.⁴  Therefore, we must aim to provide culturally proficient patient-centered care that limits biases, prejudices, assumptions, and minimize the cultural gaps.

Cultural competence is defined as the set of attitudes, skills, behaviors, and policies that enable organizations and health care professionals to work effectively in cross-cultural situations.⁵  The need for cultural competence in the health care profession is significant to assist in the reduction of racial and ethnic disparities and improve health care quality, patient satisfaction, and health outcomes.⁶  Patient-centered care is “providing care that is respectful of, and responsive to, individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions.”^7(pg1),8  Culturally competent care occurs when a medical provider acknowledges, understands, appreciates, and values cultural differences and considers those differences when caring for their patients.⁹  A lack of knowledge and inclusive care may lead to unintentional behavior or unconscious bias, creating an uncomfortable environment for patients. Evidence has shown that minority patients report greater satisfaction when receiving care from a provider who is more culturally competent or who shares the same ethnic background.^10,11  To decrease unintentional behaviors, providers should continue to expand in the 4 constructs of culturally competent care: cultural diversity, cultural awareness, cultural sensitivity, and cultural competence.¹² 

• Cultural diversity is the difference between groups based on distinguishing factors, such as race, ethnicity, national origin, gender, sex, ideology, language, disability, and generation.^12,13 

• Cultural awareness is presuming some reality can be contemplated and a corresponding capacity for processing knowledge.^12,14 

• Cultural sensitivity is a person’s attitude about themselves and others, and their openness to learning along cultural dimensions.^12,14  The focus on cultural sensitivity is approaching the person with cultural humility and taking a learner role rather than using one’s assumption.¹⁴ 

• These 3 lead to the last construct of cultural competence.^12,14  This is the ability for an individual to demonstrate certain behaviors in practice, which includes learning about the cultures represented in the community being served, adapting care to meet client needs, and documenting assessment and adaptations.^12,14 

To ensure athletic trainers (ATs) have the knowledge and skills necessary to provide patient-centered care, in 2021, the Commission on Accreditation of Athletic Training Education (CAATE) established new standards that require all accredited athletic training programs (ATPs) to practice cultural competency, foster cultural humility, and demonstrate respect in client or patient care.^14,15  The new standards allow us to draw assumptions that all ATPs are incorporating coursework and clinical education using a patient-centered approach. Despite the new standards, evidence has suggested that athletic training educators may not have the knowledge or experience of cultural competence concepts through their own education and therefore may not have the ability to adequately instruct on culturally competent care.¹⁶  The goal for integrating culturally competent education would allow for self-exploration of one’s own culture and ethnicity, becoming knowledgeable of other cultural groups, and engaging in various patient interactions with diverse individuals.¹⁷ 

Athletic training literature advocates an emphasis on cultural competence and patient-centered care. Marra et al examined the cultural competence levels of ATs in their delivery of health care services.¹³  Their findings provided a baseline for ATs and their levels of cultural competence, showing ATs who self-reported higher scores than their actual cultural competence scores. Athletic trainers also revealed that their cultural behaviors scored significantly lower than their cultural awareness and sensitivity (CAS). Secondly, Nynas investigated athletic training students’ (ATSs’) knowledge of culture and cultural differences and assessed the practice of culturally competent care.⁹  Their findings were similar, revealing higher CAS scores than behavioral scores. Lastly, Volberding investigated undergraduate ATSs’ levels of cultural competence by race, gender, and year in school.¹⁸  The findings showed racial and ethnic minorities demonstrating higher levels of cultural competence but no significant differences between gender and year in school.

The purpose of our study was to investigate ATSs’ current cultural competence using the Cultural Competence Assessment Inventory (CCA) and to determine if ATS cultural competence would increase after a diversity and inclusion education intervention. We hypothesized that, after the intervention, ATSs would demonstrate higher levels of cultural competence.

The study was a cross-sectional design with a case study approach. Our study was completed over 3 months at a private Division III institution to capture ATSs’ cultural competence levels before and after an intervention. The study was approved by the institutional review board, and all participants were provided with and signed written informed consent.

Participants were students enrolled in the professional phase of the institution’s master’s ATP. Out of 38 students in the program, 31 (21 female, 10 male) participated and are included in the final analysis.

The CCA developed by Schim and adapted by Marra was used.^13,14  Permission to use the CCA from the author was obtained before the study was performed. Researchers from many professions, including nursing, social work, medicine, education, and law, have established content, construct, and face validity and reliability of the CCA.¹³  Reliability was established with internal consistency reliability Cronbach α ranging from 0.89 to 0.92. Test-retest reliability has also been established at r = 0.85.^13,19  The assessment consisted of 30 questions on a 7-point Likert scale (0 = no opinion, 1 = strongly agree to 7 = strongly disagree) that assessed awareness and sensitivity toward cultures and the ability to demonstrate within clinical practice. The 2 subscales of the CCA are CAS and cultural competence behavior (CCB). The means of the 2 subscales (constructs) make up the overall CCA score. The assessment asked participants if they felt culturally competent, which was assessed on a 5-point Likert scale (1 = very competent to 5 = very incompetent).⁹  Lastly, demographic questions were tailored to our study and included participant’s sex, race or ethnicity, grade, hometown, previous diversity education, and percentage of completion on the diversity and inclusion intervention.

In our study, we used EVERFI’s diversity and inclusion education module as our intervention, which was deployed to all ATSs on campus. The intervention took approximately 45 minutes to complete, and participants were allowed to stop and return until they were completed. The intervention aimed to equip participants with information and skills to thrive and sustain a culture of inclusive excellence.²⁰  The intervention used realistic videos and written scenarios to relate and keep learners engaged throughout the course. Check point quizzes were used to keep learners accountable for moving forward in the intervention. Key concepts addressed in the intervention were identity, bias, power, privilege and oppression, benefits of being a part of a diverse community, and developing skills related to behavior, self-care, and creating inclusive spaces.¹⁷ 

The CCA was administered in a controlled classroom setting where each eligible participant signed an informed consent. After taking the initial CCA, participants were encouraged to complete the intervention. A follow-up e-mail from the investigators was sent 3 months after the initial CCA, requesting all participants to complete the CCA postintervention during prearranged meeting times. Before completing the postintervention CCA, participants were asked to bring verification of their participation of the intervention and self-recorded their progress on the demographic section of the CCA. Three groups were determined based on ATS completion of the intervention: Group 1 represents ATSs who completed the intervention in its entirety. Group 2 represents participants who completed part of the intervention (15%–50%). The minimum completion rate was 15%; anything lower was represented in Group 3 (0%–14%).

Overall, a high score (7) on the CCA indicates a high level of cultural competence, whereas a low score (1) indicates a low level of cultural competence.⁷  The 2 subscales’ (CAS and CCB) means serve as the total score for the CCA.⁹  We compared all demographics and CCA scores by using descriptive statistics through Microsoft Excel software, and a paired sample t test (α level .05) was analyzed using SPSS (version 25, IBM Corp). Cronbach α showed the questionnaire reached acceptable reliability: α = 0.76 and 0.77 on the CCA, α = 0.49 and 0.72 on the CAS, and α = 0.73 and 0.84 on the CCB.

Out of 38 ATS in the program, 31 participants completed the study. The average age of participants was 21.4 ± 1.20 years. Most participants identified as White (n = 25, 80.6%), and the remaining participants reported belonging to a racial and ethnic minority group (n = 6, 19.4%; Table 1). The racial and ethnic minority groups represented are Black or African American, Hispanic or Latinx, and biracial (Black or African American and White). Participants indicated their level within the ATP as first-year (n = 7, 22.5%), second-year (n = 13, 41.9%), or third-year (n = 11, 35.5%) students (Table 1).

Less than a quarter (n = 5, 16%) of participants had previous diversity education (Figure). The participants either gained education through online training (n = 3, 60%) or a separate college course for credit (n = 2, 40%). When asked if their education was athletic training specific, 60% (n = 3) reported yes, the training was specific to athletic training. All participants completed both pre- and post-CCA, but not all completed the intervention in the study. For our study, we included all participants and reported the results by groups.

Taking a closer look at sex (Table 2), then race and ethnicity (Table 3), the pre-CCA revealed females (n = 21) scored a mean of 4.26 ± 0.64, and males (n = 10) scored a mean of 4.30 ± 0.31. The findings revealed males showed slightly higher baseline CCA than females. On the post-CCA, females scored a mean of 4.71 ± 0.62, and males scored a mean of 4.51 ± 0.39. The findings revealed females had higher CCA scores than males after the intervention.

A paired samples t test revealed a positive difference when comparing the females’ CAS pre- and postscores (t₂₀ = 2.21, P = .04) and CCB pre- and postscores over time (t₂₀ = 3.74, P = .001). Males did not reveal a significant difference between pre- and post-CAS scores for either CAS (t₉ = 0.25, P = .81) or CCB scores (t₉ = 2.15, P = 0.06; Table 2).

When examining race and ethnicity data, the pre-CCA showed White ATSs (n = 25) scored a mean of 4.28 ± 0.53, and racial and ethnic minority ATSs (n = 6) scored a mean of 4.23 ± 0.65. The findings revealed White ATSs showed slightly higher baseline CCA than racial and ethnic minority ATSs. On the post-CCA, White ATSs scored a mean of 4.62 ± 0.57, and racial and ethnic minority ATSs scored a mean of 4.77 ± 0.54. The findings revealed racial and ethnic minority ATSs had higher CCA scores than the White racial group after the intervention.

After taking the pre- and post-CCA, a paired samples t test revealed White ATSs had no significant difference when comparing CAS pre- and postscores (t₂₄ = 0.48, P = .64) but significant positive differences when comparing CCB pre- and postscores (t₂₄ = 3.68, P = .001). The racial and ethnic minority ATS group revealed significant differences when comparing CAS pre- and postscores (t₅ = 2.71, P = .04) but no significant differences when comparing CCB scores pre and post (t₅ = 2.26, P = 07; Table 3).

Group 1 (n = 17) data are in Table 4. Athletic training students scored a total mean of 4.32 ± 0.62 on the CCA before the intervention. Further review of the subscales revealed a mean score of 5.53 ± 0.44 on the CAS and 3.11 ± 0.97 on the CCB (Table 4). Self-reported perceived level of cultural competence revealed a total of 81.2% (4.06 ± 0.68 out of 5). The findings indicated ATS’ CAS scores were greater than cultural behavior scores before the intervention.

After completing the intervention, the ATSs scored a total mean of 4.68 ± 0.64 on the CCA. A paired samples t test revealed a significant difference when comparing CCA pre- and postscores over time (t₁₆ = 3.62, P = .002). Further review of the subscales revealed a mean score of 5.78 ± 0.45 on the CAS and a mean score of 3.58 ± 1.13 on the CCB. Posttest self-reported perceived level of cultural competence revealed a total of 83.6% (4.18 ± 0.73 out of 5). A paired samples t test revealed a significant difference when comparing CAS pre- and postscores over time (t₁₆ = 2.32, P = .03) and CCB pre- and postscores over time (t₁₆ = 2.57, P = .2). While CASs were greater than their cultural behaviors before intervention, a significant increase was still observed in postintervention scores.

Group 2 (n = 7) data are in Table 4. Athletic training students scored a total mean of 4.35 ± 0.58 on the CCA before the intervention. Further review of the subscales revealed a mean score of 5.65 ± 0.34 on the CAS and a mean score of 3.05 ± 0.85 out of 7 on the CCB. Self-reported perceived level of cultural competence revealed a total 91.4% (4.57 ± 0.53 out of 5). The findings indicated ATS’ CAS scores were greater than cultural behavior scores before the intervention.

After partially completing the intervention, the ATSs scored a total mean of 4.78 ± 0.44 on the CCA. A paired samples t test revealed a significant difference when comparing CCA pre- and postscores over time (t₆ = 2.65, P = .04). Further review of the subscales revealed a mean score of 5.40 ± 0.73 on the CAS and a mean score of 4.16 ± 0.65 on the CCB. Posttest self-reported perceived level of cultural competence revealed a total of 88.6% (4.43 ± 0.53 out of 5). Factoring in time, a paired samples t test revealed no significant difference when comparing CAS pre- and postscores over time (t₆ = .716, P = .50) but a significant positive difference when comparing CCB pre- and postscores over time (t₆ = 8.0, P = .00). The findings suggest ATS’ CASs were less than their cultural behavior scores after the intervention.

Group 3 (n = 7) data are in Table 4. Athletic training students did not complete the intervention. After taking the pre-CCA, ATSs scored a total mean of 4.08 ± 0.29. Further review of the subscales revealed a mean score of 5.48 ± 0.44 on the CAS and a mean score of 2.67 ± 0.51 on the CCB. Self-reported perceived level of cultural competence revealed a total of 94.2% (4.71 ± 0.49 out of 5). The findings indicated ATS’ CAS scores were greater than cultural behavior scores.

After 3 months and with no intervention, ATSs scored a total mean of 4.44 ± 0.43 on the CCA. A paired samples t test revealed no significant difference when comparing CCA pre- and postscores over time (t₆ = 1.77, P = .13; Table 4). Further review of the subscales revealed a mean score of 5.68 ± 0.52 on the CAS and a mean score of 3.21 ± 1.00 on the CCB (Table 4). Posttest self-reported perceived level of cultural competence revealed ATSs self-reported a total of 88.6% (4.43 ± 0.53 out of 5). Factoring in time, a paired samples t test revealed no significant difference when comparing CAS pre- and postscores over time (t₆ = 1.40, P = .21) and no significant difference when comparing CCB pre- and postscores over time (t₆ = 1.27, P = .25). Although no significance was found, the findings suggest ATS’ CASs remained greater than their cultural behavior scores despite not having completed an intervention.

In our study, we aimed to investigate ATSs’ current cultural competence using the CCA and to determine if ATSs’ cultural competence would increase after diversity and inclusion training. Athletic training students who identified as males showed slightly higher baseline CCA score than females, but females scored higher on the postintervention CCA than males (Table 2). It was also revealed that ATSs who identified as White showed slightly higher baseline CCA scores than ATSs identifying as racial and ethnic minorities, but the racial and ethnic minority group scored higher on the post-CCA than their White counterparts (Table 3). Even though ATSs identifying as White males scored higher on baseline, our postintervention findings are consistent with previous research. Marra et al found female ATs scored higher than males, and ATs of color were more culturally competent than White or Caucasian ATs.¹³  Volberding used the Process of Cultural Competence Among Health Care Professionals, an instrument different from the CCA and modified from the nursing profession. Despite the different instrument, the author found ATSs identifying as racial and ethnic minorities scored higher perceived cultural competence scores than their White counterparts.¹⁸  Participants identifying as racial and ethnic minorities and females may have displayed higher scores in our study due to prejudice and discrimination historically experienced among the groups.¹³  Therefore, we may assume ATSs who identify as female and racial and ethnic minorities have a better understanding of critical cultural issues and are more aware than males and their White counterparts.⁹ 

Only 16.1% (n = 5) of the participants reported previous diversity education. Athletic training students self-reported a higher level of cultural competence, whereas the CCA revealed them to be less competent. The self-reported higher scores may be due to previous knowledge and attitudes toward different cultures or the intervention. Our study was conducted under the 2012 CAATE standards, in which no mention of cultural competence and patient-centered care existed that may have yielded lower scores of CAS. Lower scores of cultural behaviors may be due to lack of experience or exposure to diverse populations, which may minimize the opportunity to practice culturally competent behaviors.

Our findings support our hypothesis that ATSs demonstrate higher levels of cultural competence after an intervention. Groups 1 and 2, who completed all or part of the intervention, revealed a positive significant difference pre- and post-CCA (Table 4), whereas Group 3 did not display significant differences in pre- and post-CCA scores (Table 4). Our evidence supports the need for diversity education in all ATP curricula. Even our participants who completed a portion of the intervention achieved higher scores on the CCA. Our results also indicate ATSs understand CAS but did not necessarily display the 2 constructs within their cultural behaviors. Our results support previous research of Marra et al and Nynas, in which perceived cultural behaviors did not mirror awareness and sensitivity.^9,13  Cultural awareness and sensitivity may have improved because of the intervention. While the intervention was not patient-centered care specific, the training may have assisted in preparing the ATSs for bias, assumption, and racial conflicts. If the intervention was created through a patient-centered lens, we may have seen a larger positive influence on cultural behaviors. Overall, our findings show diversity education gives readiness and preparedness to ATSs, allowing them to provide higher levels of culturally competent care.

Bringing cultural competence to the forefront of health care is essential, particularly in athletic training. One method to improve patient-centered and culturally competent care is to increase the number of educational tools and skills throughout ATPs. Athletic training students have expressed interest in receiving more education regarding the topic.⁹  Students also expressed the most helpful method of education was engaging in discussions about cultural competence.²¹  Therefore, providing learning opportunities and modeling behaviors to students by way of faculty, preceptors, and classmates may assist in improving CCBs. An intergroup dialog workshop used by Claiborne et al improved cultural competence in ATs. They showed an increase in CAS and CCB scores postworkshop when compared with preworkshop.²²  When comparing other health professions, our findings align with Davis-Cheshire and Crabtree, who used a different assessment tool (the Inventory for Assessing the Process of Cultural Competence Among Healthcare Professionals-Revised) to evaluate cultural competence in an occupational therapy pediatric course.^18,23  They revealed diversity activity and training appeared to effectively enhance students’ cultural competence in entry-level occupational therapy doctoral students.²³  Implementing designated courses and seminars in the curriculum and increasing the number of opportunities to diverse exposure may increase students’ ability to apply patient-centered skills into clinical practice.

Our study was not without limitations. The study had a small sample size, and all participants attended the same institution, which affects the generalizability of our study. Secondly, the low racial and ethnic representation (n = 6) within our study may be perceived as a limitation. During the time of our study, ATSs were under the 6th edition of the CAATE standards, which had minimal emphasis on patient-centered care and cultural competence. The participants in the first year of the program eventually graduated under the 7th edition of the CAATE standards. The difference of standards is a limitation to the second- and third-year participants because they were not required to be exposed to patient-centered care concepts.

The Board of Certification for Athletic Training has emphasized putting culturally congruent practice at the forefront of professional standards. Culturally congruent care is the goal; one possible way to achieve it is by interconnecting the various constructs: cultural awareness, cultural sensitivity, cultural behavior, and cultural competence.¹⁴  While providers should strive toward cultural competence, we should remember cultural competence is a continuum, a developmental process with no endpoint. The starting point is developed through our lived and shared experiences and should be reinforced formally through our health care education.¹³ 

In our study, we reported ATSs’ cultural competence increased after fully or partially completing the intervention. Education and diversity training may be effective and should be emphasized in ATPs to promote the foundation for emerging professionals to possess higher levels of cultural competence, reinforce patient-centered care, and decrease health disparities. Aligning culturally congruent practice is a dynamic integration in which patient and family preferences are skillfully addressed by being inclusive of cultural values, beliefs, influences, worldview, and practices.²⁴ 

Cultural competence is critical today with the growth of diverse individuals we care for and interact with. Inside the profession of athletic training, it is important that ATs and ATSs are equipped with the proper knowledge and skills to effectively deliver culturally proficient patient-centered care.