The socioecological framework is a multilevel conceptualization of health that includes intrapersonal, interpersonal, organizational, environmental, and public policy factors. The socioecological framework emphasizes multiple levels of influence and supports the idea that behaviors both affect and are affected by various contexts. At present, the sports medicine community's understanding and application of the socioecological framework are limited. In this article, we use the socioecological framework to describe potential avenues for interventions to reduce sport-related deaths among adolescent participants.

Context: Emergency action plans (EAPs) are policies that improve response times and ensure access to emergency equipment for the management of patients with acute injuries and medical conditions, yet the extent to which EAP standards are adopted and implemented is unknown. Objective: To describe the extent of EAP adoption and implementation in secondary school (SS) athletics with athletic trainer (AT) services in the United States. Design: Cross-sectional study. Setting: Web-based questionnaire. Patients or Other Participants: A national sample of ATs (n = 9642) was invited to participate in a Web-based questionnaire. Main Outcome Measure(s): Twelve components of EAP minimum best practices were derived from the “National Athletic Trainers' Association (NATA) Position Statement: Emergency Planning in Athletics.” Emergency action plan components were analyzed using descriptive statistics with 95% confidence intervals (CIs) around proportions. Contingency tables (2 × 2) were used to calculate odds ratios (with 95% CIs) to assess adoption of the components (dichotomized as yes or no), employment factors (eg, full time versus part time, employed by clinic/district), and access to emergency equipment. Results: The response rate for the questionnaire was 13.2% (n = 1273). A majority of ATs (89.1%) reported having an EAP; however, only 9.9% described implementing all 12 components cited in the NATA position statement. Athletic trainers stated that they created the EAP in 62.8% (95% CI = 60.1%, 65.4%) of schools with an EAP. Athletic trainers employed full time were at greater odds of adopting 9 or more components of the EAP compared with ATs employed part time (odds ratio = 2.42 [95% CI = 1.66, 3.53]). A total of 85.7% of ATs noted access to an automated external defibrillator. Conclusions: Although a majority of SSs had EAPs, the EAPs were often incomplete and lacked the necessary components for full compliance with the NATA position statement. These findings demonstrate the need for efforts to promote the adoption and implementation of comprehensive EAPs in SS athletics.

Secondary schools (SSs) inconsistently adopt emergency action plans (EAPs) for athletics. To describe the barriers, facilitators, and social determinants influencing EAP adoption in SSs in the United States. Cross-sectional study. Secondary schools. A national sample of athletic trainers (ATs; n = 9642) and athletic directors (ADs; n = 9687) were invited to participate in a Web-based questionnaire. A total of 1273 (13.2%) ATs and 702 (9.2%) ADs responded to the survey. The questionnaire addressed self-reported barriers to, facilitators of, and social determinants (eg, locale, funding classification [eg, public or private SS]) of EAP adoption. The responses of ATs and ADs were analyzed separately. Barriers, facilitators, and social determinants were evaluated using descriptive statistics. Contingency (2 × 2) tables were used to calculate the odds ratios (ORs) of adopting an EAP and the presence of each social determinant. Perceived barriers to implementation were a lack of knowledge about how to implement an EAP and financial limitations. Facilitators were having access to health care personnel, state mandates, and support from a person in an authoritative position. Compared with ATs at rural schools, ATs at suburban schools displayed greater odds of having an EAP (χ² = 5.63, P = .01, OR = 1.63 [95% confidence interval = 1.08, 2.44]). According to the ADs' responses, a larger SS enrollment (≥500) led to greater odds of adopting an EAP (OR = 2.02 [95% confidence interval = 1.41, 2.89]). Perceived barriers to EAP adoption suggest that ATs and ADs need to be educated so they can provide additional information on the low cost of EAP adoption. Further, ADs described state mandates as facilitators to improve EAP adoption; therefore, efforts to educate state leaders about the need for mandated policies may be warranted. Certain social determinants (eg, school enrollment) may affect EAP adoption, but not every proposed determinant significantly affected adoption.

There are no validated, objective diagnostic or prognostic biomarkers for sports-related concussion (SRC), which hinders evidence-based treatment for concussed athletes. While quantitative electrophysiology (EEG) and diffusion tensor imaging (DTI) are promising technologies for providing objective biomarkers for concussion, the degree to which they are related has not been systematically investigated in concussed athletes. This study examined whether diffusion metrics differentiated concussed athletes with prolonged recovery ( n = 18) from non-conccused athletes ( n = 13) and whether observed diffusion alterations related to EEG. Collegiate athletes ( N = 31) completed EEG, neurocognitive, and magnetic resonance imaging. White matter diffusivity differed between the groups in multiple white matter tracts, including the corpus callosum, cingulum bundle, thalamic radiations, and inferior fronto-occipital, inferior longitudinal, and uncinate fasciculi, but not after correction for multiple comparisons. The enhanced Brain Function Index (eBFI), a measure that combines EEG and neurocognitive data, significantly correlated with altered diffusion in the concussed athletes. These preliminary findings suggest that the absolute deviation of diffusion metrics in concussed versus non-concussed athletes may have clinically utility. Results also suggested that the eBFI may be sensitive to early changes from sports-related concussion.

Context: Emergency action plans (EAPs) are a critical component in the management of catastrophic sport-related injury. Some state high school athletics associations and state legislation have required that schools develop EAPs, but little research exists on the influence of a statewide policy requirement on local adoption of these policies. Objective: To examine the efficacy of a statewide policy requirement on local adoption of an EAP. Design: Cross-sectional study. Setting: Online questionnaire. Patients or Other Participants: Secondary school athletic trainers were invited to complete a survey (n = 9642); 1136 completed the survey, yielding an 11.7% response rate. Main Outcome Measure(s): Survey responses on the adoption of EAPs along with cardiopulmonary resuscitation and automated external defibrillator (CPR/AED) requirements were cross-referenced with published statewide policies to determine the prevalence of EAP adoption. We evaluated the adoption of emergency action plan components based on the National Athletic Trainers' Association's emergency planning position statement along with CPR/AED requirements to determine component-specific prevalence. We compared the prevalence of EAP and component adoption between states that required EAPs and specific components of EAPs and states without such requirements. Results: Athletic trainers in states that required adoption of an EAP reported including more components of the emergency planning position statement (mean = 8 ± 4, median = 9) than in states without a requirement (mean = 7 ± 4, median = 8). The adoption of EAP components did not differ between states that required specific components of the EAP versus development of the EAP only. However, schools in states with both EAP and CPR/AED training requirements reported higher rates of CPR/AED training implementation (95.5%) than states that only required CPR/AED training (81.6%, prevalence ratio = 1.10, 95% confidence interval = 1.01, 1.20). Conclusions: Based on these data, statewide policy requirements for the development of an EAP may be associated with increasing adoption of EAPs.

Exertional heat stroke (EHS) deaths can be prevented by adhering to best practices. To investigate high schools' adoption of policies and procedures for recognizing and treating patients with EHS and the factors influencing the adoption of a comprehensive policy. Cross-sectional study. Online questionnaire. Athletic trainers (ATs) practicing in the high school (HS) setting. Using the National Athletic Trainers' Association position statement on exertional heat illness, we developed an online questionnaire and distributed it to ATs to ascertain their schools' current written policies for using rectal temperature and cold-water immersion. The precaution adoption process model allowed for responses to be presented across the various health behavior stages (unaware if have the policy, unaware of the need for the policy, unengaged, undecided, decided not to act, decided to act, acting, and maintaining). Additional questions addressed perceptions of facilitators and barriers. Data are presented as proportions. A total of 531 ATs completed the questionnaire. Overall, 16.9% (n = 62) reported adoption of all components for the proper recognition and treatment of EHS. The component with the highest adoption level was “cool first, transport second”; 74.1% (n = 110) of ATs described acting on or maintaining the policy. The most variability in the precaution adoption process model responses was for a rectal temperature policy; 28.7% (n = 103) of ATs stated they decided not to act and 20.1% (n = 72) stated they maintained the policy. The most frequently cited facilitator of and barrier to obtaining rectal temperature were a mandate from the state HS athletics association (n = 274, 51.5%) and resistance to or apprehension of parents or legal guardians (n = 311, 58.5%), respectively. Athletic trainers in the HS setting appeared to be struggling to adopt a comprehensive EHS strategy, with rectal temperature continuing as the biggest challenge. Tailored strategies based on health behavior, facilitators, and barriers may aid in changing this paradigm.