Delivering Patient-Centered Care With Respect to Patient Education and Health Literacy in Athletic Training Job Settings

• Athletic trainers (ATs) across college, secondary school, and physician practice settings prioritized establishing trusting relationships, fostering open communication, and ensuring transparency with patients as essential components of delivering patient-centered care.

• Despite time constraints, ATs in the physician practice setting often excel in delivering comprehensive patient education, potentially due to the structured nature and focused interactions typical of these settings.

• Enhancing patient-centered care can be achieved by ATs across various job settings through a deeper understanding of health literacy, including defining the concept, implementing screening tools, and providing responsive patient education.

In 2021, the Institute of Medicine (now the National Academy of Medicine) released the Quintuple Aim, which strategizes the priorities for health care in the United States.¹  The Quintuple Aim expands on the Triple (2008) and Quadruple (2014) Aims to now include a focus on health equity that aligns with the central tenets of patient-centered care (PCC).¹  A PCC approach respects the patient’s experience, values, needs, and preferences in planning, coordinating, and delivering care.^2–4  A central component of PCC is the therapeutic relationship between the patient and the team of health care professionals, which creates meaningful engagement with the health care system and has the patient’s wishes respected throughout decision-making.^2–4  A newer concept to PCC is replacing the “Golden Rule” with the “Platinum Rule,” by which we provide care and treatment to the patient concerning how they wish to be treated rather than how we would have liked to be treated. Using the Platinum Rule over the Golden Rule is essential in adequately using PCC, as this rule puts the patient at the forefront. Although PCC has similar principles across job settings, the demographics of the patient and the job setting may influence how this is delivered. For example, providers should consider social determinants of health factors, such as access to care and education, social risk factors, such as food insecurity and community safety, and vulnerable populations based on race, ethnicity, and culture when engaging with patients.⁵ 

Providers who create and promote a patient-centered environment can do so by exploring and addressing a patient’s health literacy levels and delivering patient education that is respectful and responsive to the individual.^2–4  Recently, Healthy People 2030 set a main goal to increase the population’s health literacy.⁶  In doing so, Healthy People 2030 elaborated on the definitions of health literacy by recognizing the need to improve the health literacy of the general population through personal and organizational means.^6,7 Organizational health literacy is defined as the “degree to which organizations equitably enable individuals to find, understand, and use information and services to inform health-related decisions and actions for themselves and others,” whereas personal health literacy is focused on the “degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others.”^6,7  A 2018 literature review suggested that adolescents from high-income and well-educated households are more likely to have parents with high health literacy.⁸  Additionally, researchers have identified that collegiate student-athletes have adequate general, digital, and musculoskeletal health literacy.^9,10  Low health literacy is most prevalent among populations with adults living below the poverty level, individuals who are 65 and older, and Hispanic adults¹¹ ; therefore, these populations are considered vulnerable populations.¹²  Vulnerable populations are disproportionately affected by factors that make them more likely to have low health literacy, such as limited access to high-quality education, limited English proficiency, type of health insurance, and cognitive impairment.^11,13  A systematic review identified increased emergency care and hospital use among people with lower health literacy, resulting in poorer health outcomes.¹⁴  It is thought that individuals with low or limited health literacy struggle to comprehend medical information, such as at-home instructions and self-care for their illness or injury.^15–17  Inadequate health literacy can lead to more frequent hospital admissions with more extended stays, being prone to missing medical appointments, and poor adherence to treatment recommendations.¹⁸ 

Health care organizations and providers unaware of a patient’s health literacy can have an immediate and lasting impact on potential outcomes.^19–21  Healthy People 2030 has set goals to increase the number of adults who report that their health care provider asks them to demonstrate how they will follow instructions, involve them in health care decisions, and reduce the number of adults who report poor patient and provider communication.⁷  It will also increase the number of people who find their online medical records accessible and the number of adults with limited English proficiency who state that their health care provider explains things in an easily understood way.⁷  This is the process of organizational health literacy in which, in the case of athletic training, the athletic training facility staff have a role and responsibility to improve the shared decision-making process by making information navigation more accessible.^22,23 

Patient education is seen as an empowering activity, consisting of a planning phase whereby the provider assesses a patient’s learning preferences and expectations, followed by setting outcomes, implementing the education via differential instructional methods while considering the place and timing, and concluding with an evaluation of outcomes.^19,24  For patient education to be meaningful and directed, the provider should explore the patient’s health literacy to determine the methods that best align with their needs.⁴  Patient education guides individuals to comprehend their condition and treatment options by providing important health information to patients and their support systems and, ultimately, empowering patients to enhance their autonomy to achieve therapeutic goals.^19,24  However, barriers to patient education include the need for additional time, unawareness of patients’ needs, the specific timing of patient education, and methods to follow up on whether patients understood what they were taught.²⁵ 

At this time, the research calls health care providers and researchers to action to increase research on health literacy and patient education to improve the provider-patient relationship and influence overall health outcomes.^{15–18,26–32}  However, there needs to be more literature on how, if at all, athletic trainers (ATs) explore their patients’ health literacy levels and deliver patient education. The Board of Certification Content Outline for Practice Analysis, 8th edition, revised the domains of clinical practice.³³  Specifically, task 0103 from domain 1 (Risk Reduction, Wellness, and Health Literacy) states that ATs must

It is essential that ATs in all settings improve their competence and use of health literacy assessment and patient education delivery to provide patients with the best care possible. More evidence is needed on patient education strategies and implementation specific to athletic training. These critical areas of information are necessary for the delivery of PCC to be affected. Therefore, the purpose of this study was to explore the lived experiences of ATs from 3 job settings—physician practice, college, and secondary school—regarding how they explore health literacy and deliver patient education to identify if they are creating a PCC environment.

The study was guided using the consensual qualitative research (CQR) tradition to explore the lived experiences of ATs in physician practice, college, and secondary school settings when creating a patient-centered environment, assessing a patient’s health literacy, and delivering patient education.^34,35  We used the Standards for Reporting Qualitative Research to guide project development and data presentation.³⁶  The institutional review board at the University of South Carolina deemed this study exempt.

Two research team members (A.M.M., Z.K.W.) developed an interview protocol to explore the lived experiences of ATs specific to the research question. The protocol was then sent to the other research team members to provide feedback. Two rounds of revisions occurred until agreement was met among all 6 members of the research team. The interview questions were modified based on feedback for wording, rephrasing, and elaborating on questions. The final interview protocol comprised 14 questions, including 4 regarding PCC, 4 on health literacy, and 6 on patient education. Before data collection, the interviewer (A.M.M.) conducted a pilot test of the interview (not included in data analysis) to rehearse and ensure professionalism and consistency in the interview process. No additional edits were made to the interview protocol after the pilot test. Table 1 provides the interview protocol used for all participants regardless of job setting.

We used a multimodal recruitment process, including social media postings, specifically on Facebook and X (formerly Twitter), and through the National Athletic Trainers’ Association (NATA) research database to identify potential participants from the physician practice, college, and secondary school settings. To begin recruitment, we emailed 1000 NATA research database AT members. We evenly distributed recruitment among the college, secondary school, and physician practice job settings (approximately 333 ATs per setting). The email contained an invitation to participate in a short web-based demographic survey (Qualtrics, Inc). At the end of the survey, the participants were asked to provide their preferred email address to set up their one-on-one interview. We then responded to the interested participants to set up a date and time for the interview.

In total, 47 recruitment surveys were completed from NATA and 28 from social media. Of the 75 potential participants who responded to the survey, 5 did not wish to participate, and 20 did not provide their demographics or contact email, leaving 50 individuals eligible. We completed interviews to align with best practices in CQR methodology to compare nonhomogeneous samples, meaning we needed at least 7 ATs per job setting while also seeking data saturation.³⁴  In total, 27 ATs (age = 34 ± 10 years; women = 15, men = 12; clinical experience = 10 ± 9 years) from either the physician practice (n = 10), college (n = 9), or secondary school (n = 8) setting completed the study. Table 2 provides the full demographics of the participants.

One research team member (A.M.M.) conducted each audio-only interview through a web-conferencing platform (Zoom Video Communications Inc) between June 2023 and August 2023. At the onset of the interview, participants provided verbal informed consent. The researcher then conducted a semistructured interview guided by the interview protocol. Throughout each interview, the interviewer engaged in reflexivity by taking notes to address their biases and assumptions, specifically to acknowledge previous employment and socialization experiences in college and secondary school settings. The interviews lasted, on average, 29 minutes. After the interview, the audio files and transcripts were downloaded. The interviewer deidentified the transcriptions and saved them to a secured cloud server. This ensured the participant’s protection and an unbiased data analysis process, as a member of the coding team was also the interviewer. Participants were sent their transcripts to verify the accuracy of the transcript. Two participants sent additional edits to their transcripts during member checking.

The extensive research team on this project has a noteworthy background. The authors are a mix of clinicians (A.M.M. = secondary school, T.A.A. = college, T.J.P.G. = physician practice) and educators (E.R.N., L.E.E., Z.K.W.) with previous athletic training experience in college and secondary school settings. Our firsthand experiences, academic training, and prior assumptions might have influenced how we interacted with participants or reviewed the data during coding.

To analyze the data, we used the CQR method, which allows the researchers to document the personal experiences of ATs, analyze the data, and agree on a common interpretation of the findings.^34–36  To minimize researcher bias and establish consensus, interview transcripts were analyzed by 3 separate 3-person coding teams dependent on experience in a job setting (physician practice, college, secondary school).

To begin phase 1 of data analysis of the physician practice transcripts, 3 coding team members (A.M.M., L.E.E., T.J.P.G.) read and reviewed 4 physician practice transcripts and created a domain list, categories, and subcategories from the participant responses. The coding team then met for consensus on commonalities and made the physician practice codebook. In phase 2 of data analysis, each coding team member read and reviewed 2 transcripts used in the first phase of review and 2 new physician practice transcripts to verify that the preliminary codebook represented the data. The team once again met for consensus on commonalities to finalize the physician practice codebook. In phase 3A of data analysis, the coding team evenly divided and coded the remaining unique physician practice transcripts for the domains and categories within the consensus codebook. In phase 3B, transcripts were exchanged among the code team to cross-check each other for the accuracy of the consensus physician practice codebook. A final consensus coding meeting was planned, at which all codes were confirmed with at least two-thirds agreement.

The data analysis process was repeated for the college and secondary school and transcripts with a different coding team for each job setting (college: A.M.M., E.R.N., T.A.A.; secondary school: A.M.M., E.R.N., Z.K.W.). The final coded transcripts and codebook were then sent to an individual of the research team for an internal audit for coding accuracy (physician practice: Z.K.W.; college: Z.K.W.; secondary school: L.E.E.).

Categories were assigned as general (all or all but 1 transcript), typical (fewer than general but more than half of the transcripts), variant (fewer than typical but more than 2), or rare (1 or 2 transcripts) depending on the job setting and the number of participants who mentioned that category during their interview.^34–36  The research team established trustworthiness and credibility through member checking, triangulation, and internal auditing. The final steps of the research process consisted of developing narrative counts across cases and describing illustrative cases by extracting select quotes to represent each category.

Four domains emerged during the analysis: work environment, essential traits and skills, health literacy assessment strategies, and patient education materials and delivery. Based on the participants’ responses, each job setting had the same domains but distinct categories, which are represented in the Figure. Table 3 provides the frequency counts by job setting and domain and a description of each category.

Table 4 provides extracted quotes for this domain by job setting. Participants from the physician practice setting expressed that they often saw many patients, which affected the delivery of patient education. The characteristics of the patients, specifically comorbidities and social determinants of health, usually created complex patient education needs. Participants noted that the work environment provided opportunities to work collaboratively and receive feedback on patient satisfaction. Particularly, Felicity discussed receiving feedback from patients and using it to improve her practice:

The collegiate ATs described their work environment as challenging based on the patient to provider ratio, resources, and facilities that led to time and space concerns. In addition, the ATs stated that daily access to patients and concurrent interprofessional practice allowed for continuity of care. Specifically, Courtney discussed seeing patients every day, stating, “In a university setting, I think it might be a little bit easier than some of their settings because we see our patients every day by being at their practices and their games.”

Finally, ATs in the secondary school setting discussed concerns about their facility, with privacy, resources, and space being issues. Participants also discussed providing care for various patients, differing on social determinants of health, faith, volumes, and sports. Frederick stated having issues with privacy and space being an issue with their large patient load:

Table 5 provides extracted quotes for this domain by job setting. The ATs in physician practice described their essential traits and skills for delivering PCC through shared decision-making, transparency, and providing options. Interpersonal communication through verbal mechanisms and nonverbal recognition were also discussed. Remy discussed delivering PCC in his practice and considering the patient as a whole when creating a treatment plan:

Collegiate ATs suggested that rapport with the student-athletes facilitated a trusting relationship that influenced their interpersonal communication. These essential traits and skills created a patient-centered environment that allowed them to explore the student-athlete’s life outside and after sport. Specifically, Umar discussed providing care for athletes and keeping their health and safety as a priority over their sport:

Finally, ATs in the secondary school setting discussed educating their patients on autonomy and fostering ownership of their care by encouraging them to be vocal and engaged, advocating for themselves, providing their input, and making decisions based on the ATs’ recommendations. Participants also discussed being transparent with patients, giving them reminders about their open-door policy, being available, and being honest with the patient. Jose described giving patients the opportunity to participate in shared decision-making when it came to their rehabilitation plans:

Table 6 provides extracted quotes for this domain by job setting. Regarding health literacy assessment, the physician practice ATs reported using patient input and perceived expertise to determine patient health literacy. However, they expressed struggles in assessing patient health literacy due to language barriers and needing to know the definition of health literacy, which leads to not measuring it. Angela described struggling with assessing the patient’s health literacy if they did not speak the same language:

Most participants from the college setting noted they had no formal process but used nonverbal perceptions such as reading facial expressions to gather information. The ATs also expressed confirmation bias in that they often overlooked health literacy assessments for those athletes with insurance or a health-related academic major. Specifically, Jo detailed that she did not use a formal process when assessing health literacy: “I do not do anything specific to try and measure [health literacy] other than just being an active listener.”

ATs in the secondary school setting discussed assuming a patient’s health literacy based on individual traits such as background, language, word tense, location, disabilities, and experience with injury. Participants also assumed a patient’s health literacy based on external traits such as the patient’s parent or guardian’s experience with the doctor and the parent or guardian’s attitudes toward health care, which then manifested similarly in the child. Lastly, the ATs discussed verifying the patient’s comprehension to assess health literacy using knowledge checks/teach-back, one-on-one follow-up meetings, and distinct questions for middle school versus high school athletes. Jane described making individual assumptions about her patients’ health literacy levels based on age and education level:

Table 7 provides extracted quotes for this domain by job setting. The participants from the physician practice setting discussed patient education as an ongoing, personalized process complemented by digital resources and supplemental teaching. When delivering patient education, the struggles they identified were knowing how to modify for a specific patient and limited time. Kari disclosed that in her practice, she took time to provide one-on-one patient education to ensure the patient had a full understanding of the treatment plan:

Collegiate ATs used their self-perception of the patient’s health literacy to guide the patient education they delivered. The participants often used plain language, health informatics, and question prompting to ensure patient education was well received. Specifically, RJ stated that he used health informatics such as pictures on the patient’s phone as a method of delivering patient education:

Finally, ATs in the secondary school setting discussed providing complementary handouts and visuals to deliver patient education, such as using models, diagrams, charts, and videos, and changing their approach based on the patient’s learner type. Also, they discussed engaging with parents or guardians during patient education to relay health information about their child and following up with the parent or guardian to answer any questions they had. Lastly, the ATs discussed using inclusive and thorough communication by checking in with the patient during rehabilitation sessions, avoiding medical jargon, describing things differently if they were not understood by the patient, simplifying information, and translating what they knew to the patient regarding their illness/injury. Sasha detailed that in her practice, she kept a support system involved when delivering patient education, whether that was parents/guardians, coaches, or a teammate’s parent:

We asked participants to share their experiences assessing health literacy, delivering patient education, and creating a patient-centered environment in their designated job settings. Based on the findings, ATs’ practice of PCC differed by job setting. The patient experience was important to each AT; however, there were some discrepancies in formal health literacy and patient education strategies that need to be further explored.

First impressions and nonverbal communication are essential when creating a patient-centered environment. The first impression made of the clinician by the patient occurs within the first 7 seconds of the patient encounter,³⁷  and 60% of communication is nonverbal, such as body language, eye contact, and gestures.³⁷  The 6 domains of PCC supported by the National Academy of Medicine include respect for values and preferences, coordinated care that emphasizes physical comfort, addressing fears and concerns, involving their social support systems, and providing communication and patient education.^2–4  The barriers to PCC include increased workload, focus on task completion, the power imbalance between patients and health care professionals, patients and families not seeking opportunities to be involved in decision-making, cross-cultural factors, and a lack of health literacy.^2–4  During the interviews, we heard participants discuss the domains of PCC and the barriers listed above; however, the overall application of these concepts could have been better. During the interview, participants talked about creating a relationship with the patient, privacy, communicating with and listening to the patient, asking about life outside of the injury/condition, including support systems, and encouraging the patient to participate in decisions involving their care.

An article by Berkman et al states that various definitions of health literacy exist in the United States and that the definitions evolve based on new technology and developments worldwide.^14,38  Overall, a lack of consensus about the definition of health literacy could hinder progress in its measurement and delay care.³⁸  On the other hand, the range of definitions shows that health literacy is a complex subject and that different definitions may be needed depending on the patient and the clinician’s goal.³⁸  Also, health literacy levels vary among the general population.¹⁴  An individual’s social determinants of health, including age, health status, chronic disease, access to insurance, race, alcohol and drug use, and experience with health care, can influence their health literacy.¹⁴  With respect to athletic training and sports health care delivery, the social determinants of health may differ based on the patient populations that providers engage with. Picha et al provided a comprehensive overview of social determinants of health and how they intersect with health care delivery.⁵  Some participants acknowledged these patient qualities with health literacy levels when defining health literacy and their assessment strategies; however, some definitions and assessments needed to be corrected and made more effective.

Measuring health literacy is best done by using a validated assessment tool.^14,38,39  The most widely used tools to assess health literacy are the Rapid Estimate of Adult Literacy in Medicine, the Test of Functional Health Literacy in Adults, and the Newest Vital Sign.^39,40  Although health literacy is adequately evaluated using a validated tool, none of the participants in our study used or discussed a validated tool. The Agency for Healthcare Research and Quality provides tools to improve organizational health literacy using health literacy universal precautions. As for bloodborne pathogen universal precautions, the toolkit uses an evidence-based framework suggesting that all health information be structured in a manner that is simple and understandable for all people to reduce our implicit and explicit bias in choosing who may need help navigating health information.⁴¹  However, universal precautions limit the engagement of health equity. In achieving the Quintuple Aim, ATs who are creating a patient-centered experience should begin with the health literacy universal precautions and then proceed to an individualized care plan specific to the values and needs of the patient. All participants used verbal/nonverbal communication with the patient and assumptions, bias, and self-experience to assess health literacy. Additionally, many participants discussed that their patients had various health literacy levels in their job settings. Participants stated they perceived that most, few, or half of their patients were health literate. Our study exposed that ATs are not yet competent in health literacy assessment. A lack of proficiency and expertise with this skill can hinder the quality of patient education ATs deliver and the creation of a patient-centered environment.³⁷ 

In the interest of improving health systems, ATs should contribute to creating a health-literate organization. The 10 principles of a learning health system framework include leadership prioritizing health literacy; integration of health literacy into planning, evaluation, patient safety, and quality improvement; preparing the workforce to be health literate; integrating patients and community members into the design, implementation, and evaluation of services; meeting the patients where they are without stigmatization; using health literacy in interpersonal communication; providing easy access to information and services; designing and distributing print, audiovisual, and social media content that is easy to understand and to act on; addressing health in high-risk situations; and communicating clearly about health insurance coverage and what patients will need to pay.⁴²  A critical component of creating a health-literate organization is developing a health-literate workforce, which requires just-in-time support, assessment and ongoing personalized development, and a regular cycle of analyzing training needs and gap identification.⁴²  No efforts to assess patient health literacy can be addressed without a health-literate workforce and a learning health system, so even if an AT is capable of assessing patient health literacy but is unaware of how to address it individually or organizationally, patient needs will not be appropriately addressed.

Patient education practices must be continually improved to increase positive health outcomes and ensure that health care providers are updated on recommendations.^19,24,43  Additionally, a study by Eloranta et al involving orthopaedic nurses’ perceptions of patient education practice during 9 years at a university hospital in Finland showed no positive change in the nurses’ patient education skills or the implementation of patient education.¹⁹  The study results indicated that patient education practices will not change simply through on-the-job interactions without intentional professional development and interventions.¹⁹  ATs should learn about and apply a standardized approach to patient education by identifying the patient’s health literacy level and not assuming; this way, patient education methods will be adjusted depending on the patient’s health literacy level to ensure effective patient education strategies are applied.³⁷  A commentary from Madden and Tupper published in the Journal of Athletic Training in 2024 provides a comprehensive overview of strategies that an AT can use.⁴⁴ 

It is essential for the patient to contribute and participate in the health care experience by asking 3 questions: What is the main concern? What do they need to do about it? Why is it important for them to do this?⁴⁵  This follows the Institute for Healthcare Improvement Ask Me 3 program, which focuses on a patient-centered approach to education.⁴⁵  Other elements to consider include a show-me method, in which the patient models the behaviors they will do once they leave your health care facility, or using a chunk-and-check approach, in which the provider pauses and checks for understanding after every 3 to 5 pieces of information.⁴⁶  When responding to the patients, the provider should use plain, nonmedical language to ensure they are given the necessary information and can understand it. During this responsive dialogue, the AT should address culture and social determinants of health and seek feedback.

Following patient education, repeating and summarizing the necessary information, and using the teach-back method will ensure that the patient understands the information given to them.³⁷  The teach-back method involves asking the patient to repeat the information stated by the clinician in their own words.³⁷  During this process, incorrect information is corrected, and correct information is reinforced continuously until both parties are satisfied.³⁷  Data from a national household survey in the United States identified that only 29% of health care providers used a teach-back method.⁴⁷  Participants mentioned patient education delivery strategies such as handouts, digital modes, communication in plain language, and the teach-back method. Yet patient education is not adequately delivered without sufficient assessment of the patient’s health literacy.³⁷  Based on their lived experiences, our study’s participants seem insufficiently skilled in health literacy assessment. Participants demonstrated that patient education was a comfortable concept for them, yet the best patient education is not being used without adequately assessing the patient’s health literacy.

For example, we recommend that ATs in the physician practice setting use brief live questioning, such as 3 questions to identify inadequate health literacy: “How often do you have someone help you read hospital materials?” “How confident are you filling out medical forms by yourself?” and “How often do you have problems learning about your medical condition because of difficulty understanding written information?”⁴⁸  The use of a brief questioning process in a face-to-face format may allow ATs in this job setting to intervene quickly, as patients may not return for future visits. Additionally, it may be helpful for secondary school ATs to consider the parents’ or guardians’ health literacy, as well as that of the patients, by using tools such as the Parent Health Literacy Questionnaire⁴⁹  to address caretaker health literacy and the Rapid Estimate of Adult Literacy in Medicine–Teen⁵⁰  for high school-age–related questions. These specific tools could be administered during preseason sports meetings or mass preparticipation screenings. Finally, ATs in the college/university setting may benefit from conducting a health literacy assessment quiz, like the exam provided in the Health Literacy Universal Precautions Toolkit (3rd edition).⁵¹  Data could be collected in such a way that embraces the competitive nature of college athletics. The information gleaned from the quiz can then be paired with the student-athlete’s background, including their field of study, socioeconomic background, and gender, to adapt the patient education approach.⁵² 

This study has some limitations. Social science research has an inherent self-selection participant bias. The participants in this study came from various educational and personal backgrounds; however, we did not identify everyone’s specific professional development in these areas. Additionally, some participants expressed that they had worked in other job settings, which may have influenced some of their answers.

It is vital for researchers to explore further the most effective ways of assessing health literacy and delivering patient education to foster a patient-centered environment. To do so, we recommend that quantitative studies be performed exploring the extent to which ATs deliver PCC by job setting. In addition, future work should explore continuing professional development in these critical areas using multimodal strategies such as simulation and interactive lectures.

ATs in the physician practice, college, and secondary school settings have different experiences with health literacy and patient education. The patient demographics and culture of these settings vary, making for a unique and varied approach to creating a patient-centered environment. We identified a need to explore and improve organizational health literacy to assess a patient’s understanding and be skilled in identifying, adjusting, and providing patient education specific to each AT job setting, resources, and training. Using effective health literacy assessment strategies and methods for patient education delivery will create a patient-centered environment, allowing patients to obtain the best health outcomes.